WASHINGTON—The Senate Finance Committee is scouting for ideas that might break a massive logjam of denied Medicare claims appealed by providers and suppliers.
The backlog now exceeds 500,000 cases across the first three of five levels of appeal for denied claims, Finance Committee Chairman Orrin Hatch (R-Utah) said during a hearing Tuesday that included testimony from claims administrators and the CMS' Office of Medicare Hearings and Appeals (OMHA).
The average number of days for an appeal to be processed has grown from about 95 in fiscal 2009 to 547 projected in fiscal 2015, according to the OMHA.
“The backlog of cases is so enormous that the door to new appeals is closed,” Sen. Ron Wyden (D-Ore.), the committee's ranking member, said during a hearing Tuesday. “New cases are no longer being heard.”
The CMS could make changes to the initial level of appeals that would streamline or obviate access to the subsequent levels, according to Sandy Coston, CEO of Diversified Service Options, a Medicare administrative contractor (MAC).
For example, she said, MACs could take a triage approach to appeals. They would send complaints that are clinical in nature directly to the second level of appeal, which is overseen by qualified independent contractors (QICs), which often have providers weigh in on their decisions.
“Limiting the MAC appeal casework to those nonclinical cases would allow the MAC to focus its dollars on the cases most likely to be reversed at this level,” Coston said during the hearing. “The QIC would then be positioned to handle the appeals involving a more complex level of clinical decisionmaking.”
Coston also suggested that providers and suppliers pay a per-claim filing fee that would be refunded on appeals that prevail. The fee, she said, would discourage appeals that have little chance of succeeding and also provide funding to beef up the staff and resources dedicated to processing appeals.
Greater use of electronic records would also help a great deal, according to Thomas Naughton, senior vice president of Maximus Federal Services, a QIC.
Currently, QICs are required to provide administrative law judges at the Office of Medicare Hearings and Appeals with paper case files, even though the QICs most likely received the case as electronic records.
“This means we are receiving electronic records and printing, organizing, packaging, shipping the files,” Naughton said. “Fully electronic communication and access to a case will provide the program significant time and cost efficiencies while ensuring access to the complete case file.”
Nancy Griswold, chief administrative law judge at the OMHA, suggested that cases should be knocked down to the first level of appeals whenever evidence is submitted that wasn't seen by the administrative contractor.
“This proposal provides a strong incentive for all evidence to be produced early in the appeals process and to ensure the same record is reviewed and considered at the second and subsequent levels of appeal,” Griswold said.
