What Should OMHA Do to Clear the Medicare Claims Appeals Backlog?

Posted: December 19, 2014

It obviously depends on your perspective. The nation’s largest hospital industry group recently blamed Medicare Recovery Audit Contractors (RACs) for the backlog and called for fundamental reforms of the RAC process. The American Hospital Association (AHA) made its recommendations in a Dec. 4 comment letter to the Office of Medicare Hearings and Appeals (OMHA) at the Department of Health and Human Services.

Representing an opposing view, a Dec. 3 letter from the American Coalition for Healthcare Claims Integrity (ACHCI), which represents the RACs, defended the program and recommended procedural steps and program changes to the appeals system to help reduce the backlog. Acongressional report recently indicated there are 750,000 appeals in the backlog.

In early November, the OMHA issued a request for information (RFI) seeking input about ways to reduce the backlog of appeals currently at administrative judge law (ALJ) level. In its RFI, the OMHA said it is seeking public input about previously announced initiatives to reduce pending claims appeals and requests for hearings at the ALJ level. Comments were due Dec. 5.

The AHA said it understood that the OMHA has taken steps to increase its adjudicatory capacity “to create efficiencies in case handling.” However, the group also said the OMHA’s efforts fail to directly address the root cause of the appeals backlog, which is “excessive inappropriate denials of claims” by RACs. In addition, the AHA said RACs improperly deny short inpatient hospital stays. These denials “have swollen the number of ALJ appeals,” it said.

For its part, the ACHCI, recommended “consistency in the application of Medicare policy” as one ALJ level reform. The group seemed to say that some providers are abusing the inconsistent application of Medicare policy. Noting that overturn rates among administrative law judges range from 18 to 85 percent, the ACHCI said some providers appeal every single audit. These appeals “frequent fliers,” have contributed to the appeals backlog, the group indicated.

Source: Bloomberg BNA