A proposed rule published yesterday in the Federal Register looks to stem the growing backlog of Medicare coverage and payment appeals that presently exceeds 750,000. HHS estimates that the proposed rule would reduce the number of appeals sent to Administrative Law Judges (ALJs) by 23,650 per year. Comments on the proposed rule are due on August 29th.

Key provisions of the proposed rule:

• The Chair of the Department Appeals Board (DAB) would have authority to designate decisions meeting certain criteria as precedential as a means of enabling more consistent appeals decisions and allow providers to better assess whether a given claim should be appealed. Only those decisions in which a “significant legal or factual issue was fully developed on the record and thoroughly analyzed” would qualify to be deemed precedential. Any such decision deemed precedential would be published in the Federal Register and posted on the Department of Health and Human Services (HHS) website.
• Attorney adjudicators will be utilized in a variety of respects to lessen the burden on ALJs. Specifically, attorney adjudicators will be authorized to issue appeal dismissals when an appellant withdraws and ALJ hearing request; issue remands for additional information; conduct reviews of lower level contractor denials; determine whether a claim meets the minimum amount in controversy; and hear lower-value claims. All matters decided by an attorney adjudicators will be appealable to an ALJ.

 

LeadingAge will be seeking input from its Legal Committee on the proposed rule. Any members, particularly Attorney Members, with comments on the rule are urged to provide those comments to Jennifer Hilliard (jhilliard@leadingage.org) on or before August 19th.

 

A 399-page pre-publication display version of the proposed rule is available at: https://www.federalregister.gov/articles/2016/07/05/2016-15192/medicare-program-changes-to-the-medicare-claims-and-entitlement-medicare-advantage-organization