Medicare appeals at the administrative law judge level will be suspended for two years due to backlog, agency announces

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Former nursing home worker confesses to murdering resident in 2007
Former nursing home worker confesses to murdering resident in 2007

Long-term care providers filing to have a Medicare claims appeal heard by an administrative law judge will not have the case assigned to a judge for at least two years, according to the Office of Medicare Hearings and Appeals.

A tremendous increase in appeals has swamped the 65 ALJs who hear disputes over Medicare claim determinations, OMHA Chief Administrative Law Judge Nancy J. Griswold wrote in a memorandum obtained recently by the Bureau of National Affairs. To give the judges time to work through this backlog, OMHA stopped assigning new hearing requests from providers as of July 15, 2013, Griswold disclosed. Beneficiaries' appeals will continue to be processed, to safeguard patients, she wrote.

The weekly influx of hearing requests surged from an average of 1,250 in January 2012 to more than 15,000 in December 2013, according to the memo. There now are more than 460,000 pending appeals, yet OMHA's resources have been constricted due to sequestration-related budget cuts.

The American Hospital Association blasted OMHA's decision to slow the appeals process. The move violates the Medicare statute, which requires administrative law judges to issue decisions within 90 days of receiving a request for a hearing, asserted AHA Executive Vice President Rick Pollack, in a Jan. 14 letter to top government officials.

Medicare recovery audit contractors are driving up the appeals backlog by issuing “excessive inappropriate denials,” Pollack wrote in his letter to Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner and Health and Human Services Secretary Kathleen Sebelius. OMHA and CMS are separate agencies in Sebelius' department, and they should coordinate with each other to address this problem, Pollack urged.

OMHA has scheduled a forum on this policy change, to be held Feb. 12 in Washington, D.C. There may be a call-in option or live streaming of the event.

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