Medicare Revises their Appeals Process

by  Wyn Staheli, Director of Content - innoviHealth
Feb 6th, 2017

On January 17, 2017, a Final Rule was published in the Federal Register outlining changes to the Medicare Appeals process in an order to streamline procedures and reduce the current backlog of appeals at the third and fourth levels of appeal. This new policy takes effect on March 20, 3017. According to the notice:

This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures that the Department of Health and Human Services follows at the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council (Council) levels of appeal for certain matters affecting the ALJ level.

Additional funding has been requested in the budget to alleviate the situation, but that cannot resolve the problem alone. The final rule focuses primarily on the third level of appeals - Hearing by an Administrative Law Judge (ALJ).

To review all the changes, see the Fact Sheet listed in the references below. Here are some notable changes.

• Create a new position - an attorney adjudicator who may:
  • decide appeals where a hearing is not required,
  • review dismissals issued by a Qualified Independent Contractor (QIC) or Independent Review Entity (IRE),
  • issue remands to Centers for Medicare & Medicaid Services (CMS) contractors, and
  • dismiss requests for hearing when an appellant withdraws the request. 
• Create efficiencies such as eliminating unnecessary steps and streamlining certain procedures (e.g., allowing telephone hearings in certain situations).
• Allow Medicare Appeals Council decisions to create precedence which will make the decision-making process consist among all levels of appeals.
• Update the process by which the Amount In Consideration (AIC) is calculated.