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New Data Shows Progress in Reducing Home Health and Hospice Appeals Backlogs at ALJ Level

Posted on Friday, October 5, 2018 1:33 PM

Medicare law requires providers to have a hearing and decision from an Administrative Law Judge (ALJ) within 90 days of request.  If the decision is not rendered consistent with that standard, the appellant can accelerate the appeal to the next level.   In recent years ALJ appeals have been increasingly backlogged with an expected delay of, minimally, two to three years before matters are scheduled and heard. 

Earlier this year, CMS launched a Low Volume Appeals (LVA) process to allow providers whose appeals are validated to received 62% of the approved Medicare amount.  CMS also introduced Settlement Conference Facilitation Process for larger appeals.  “The National Association for Home Care & Hospice (NAHC) recently secured data reflective of scope and timeliness of appeals resolution at the ALJ level during 2016, 2017 and 2018 for home health and for hospice.  The appeal load for home health is much higher than that of hospice, reflecting the longstanding issues related to the home health face-to-face requirements.  The increase in the percentage of dismissed claims is the result of large settlements being processed (such as those addressed through the LVA and Settlement Conference Facilitation Process). When an appellant settles its claim with CMS, it withdraws its request for a hearing and this is reflected as a dismissal.”

Here is the data the NAHC collected:

PLEASE NOTE:  The OMHA “year” follows the federal fiscal year, so data for 2018 is not complete.

Appeal Category: Home Health

 

Decisions

2016

%

2017

%

2018

%

Favorable

1,128

11.64%

807

14.61%

975

1.70%

Partially Favorable

377

3.89%

179

3.24%

99

0.17%

Unfavorable

7,457

76.93%

3,581

64.81%

1,505

2.62%

Dismissed

731

7.54%

958

17.34%

54,875

95.51%

TOTAL

9,693

 

5,525

 

57,454

 

 

Appeal Category: Hospice

Decisions

2016

%

2017

%

2018

%

Favorable

244

50.94%

680

51.91%

363

26.46%

Partially Favorable

18

3.76%

7

0.53%

8

0.58%

Unfavorable

141

29.44%

410

31.30%

213

15.52%

Dismissed

76

15.87%

213

16.26%

788

57.43%

TOTAL

479

 

1,310

 

1,372

 

Report run date: Aug. 31, 2018

Source: NAHC Report


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