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Judge Orders Backlog of Medicare Appeals to Be Cleared by 2021

Posted on Thursday, December 8, 2016 4:29 PM

In the midst of health care providers waiting patiently for a victory on lengthy appeals, a federal judge ordered the Department of Health and Human Services (HHS) to eliminate its backlog of Medicare appeals.

Health care providers that receive fee-for-service claims denials can appeal those decisions. The number of appeals filed by healthcare provides has increased over the past few years. In 2015, 123 million Medicare fee-for-service claims were denied.

“The court’s final ruling may finally spur concrete action by the Centers for Medicare & Medicaid Services (CMS) to reduce what are wholly unreasonable delays in providing appeal rights to Medicare beneficiaries and providers of health services,” William Dombi, vice president for law at the National Association for Home Care and Hospice (NAHC), told Home Health Care News.

AHA celebrated the decision as a “victory” for hospitals.

The appeals process has been considered a huge relief for the home health industry. However, larger reforms may be required to combat the high number of appeals at the front-end of the claims and auditing process, NAHC argues.

“Much of the increased appeals backlog is due to overzealous claims audits through Medicare,” Dombi said. “We hope that CMS recognizes that part of the solution lies in its reduction of unreasonable and arbitrary claim denials that force providers into an appeal just to obtain what they should be paid. Unless that occurs, the backlog in appeals will only increase in spite of the court’s order.”

Due to the judge’s final rule, HHS is required to eliminate the backlog of appeals claims before the end of 2020.

HHS has provided a timeframe to reduce and eliminate backlog over the next few years:
• 30% reduction of backlog cases December 31, 2017
• 60% reduction in backlog by December 31, 2018
• 90% reduction in backlog by December 31, 2019
• Elimination of backlog by December 31, 2020

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