Extra audits clog and freeze Medicare appeals process

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AHCA President and CEO Mark Parkinson
AHCA President and CEO Mark Parkinson

Providers who want to have an administrative law judge consider a Medicare claim appeal can save their breath and memos for now.

The Office of Medicare Hearings and Appeals (OMHA) announced that cases seeking an ALJ hearing would not be assigned to a judge for at least two years.

Sixty-five administrative law judges are now slogging through a backlog of nearly 500,000 Medicare-claims appeals, according to an official memorandum obtained by the Bureau of National Affairs.

The office of hearings and appeals ceased assigning hearing requests last July 15, acknowledged OMHA Chief Administrative Law Judge Nancy J. Griswold in the memo.

From January 2012 to December 2013, hearing requests skyrocketed from about 100 per week to more than 12 times that much, according to the memo.

Critics of the decision include the American Health Care Association. 

“There needs to be fewer inaccurate Medicare contractor audits — which are increasing appeals significantly — or additional resources provided to OMHA,” said AHCA President and CEO Mark Parkinson. “If not, the backlog could cause disruptions to beneficiary access to healthcare, especially to nursing and therapy services.”

Parkinson released his statement after OMHA held an all-day forum to discuss the issues Feb. 12.

“Our serious concerns remain,” Parkinson said. “Unless policy and process improvements are introduced soon, the appeals process will become even more dysfunctional.”

“Excessive inappropriate denials,” are clogging the review and appeals process,  added an American Hospital Association executive.


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