Share this e-Alert:

Polsinelli - Health Care Polsinelli - Health Care
         

  

June 2015

  

Senate Committee Passes Bill Addressing Medicare Appeals Inefficiencies

  

 
 

  

     

  

 
 
Law Firm of the Year - U.S. News and World Report - Health Care Law - 2015
 

For more information about this e-Alert, please contact:

  

R. Ross Burris, III

Author

404.253.6010

Email | Bio

  

Jason T. Lundy

Author

312.873.3604

Email | Bio

  

Meredith A. Duncan

Author

312.873.3602

Email | Bio

  

Health Care Practice Leaders:

  

Matthew J. Murer

Practice Area Chair

312.873.3603

Email | Bio

  

Jane E. Arnold

Practice Area Vice Chair

312.622.6687

Email | Bio

  

Colleen M. Faddick

Practice Area Vice Chair

303.583.8201

Email | Bio

  

To learn more about our Health Care practice, to contact one of our Health Care attorneys, or for more Health Care Intelligence, click here.

  


View Polsinelli documents on JD Supra  

SUBSCRIBE

 
LinkedIn Twitter Facebook Polsinelli Podcast Connect with us on LinkedIn. Connection with us on Twitter. Connect with us on Facebook.
   

On June 3, 2015, the Senate Finance Committee passed an original bill that aims to streamline and improve the Medicare Audit and Appeals Process. The Medicare appeals process has recently faced scrutiny from industry leaders for inefficiencies and a growing, almost two-year backlog of requests at the Office of Medicare Hearings and Appeals (OMHA) for hearings in front of an administrative law judge (ALJ).

Critics of the proposal note that the bill does not adequately address underlying issues in the Medicare appeals process. Nevertheless, providers should remain cautiously optimistic that proposed changes in the bill may address inefficiencies that have prevented timely recovery of improperly denied claims.

Medicare and Medicaid Payment Suspensions

The Audit & Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) Act of 2015 proposes an extensive overhaul of the current process. Proposed changes in the bill include:

  • Establishing a new Medicare Magistrate program, which would allow attorneys with expertise in Medicare law to review claims with an amount in controversy less than $1,460.
  • Raising the amount in controversy for review by an ALJ to $1,460, to match the amount for review by a district court.
  • Accelerating the appeals process by allowing for the use of sampling and extrapolation of claims. OMHA previously introduced a pilot program for statistical sampling in 2014.
  • Establishing a voluntary alternate dispute resolution process, which allows for multiple claims with similar issues to be settled together instead of separately. OMHA previously introduced a pilot for this initiative, called the Settlement Conference Facilitation Pilot, in 2014.
  • Creating a system of eligibility for hospitals with low error rates to receive one-year exemptions from post-payment audits by recovery audit contractors (RACs) and Medicare Administrative Contractors.
  • Improving oversight for the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid (CMS) over the auditors and claims appeals process.
  • Creating an independent Ombudsman for Medicare Reviews and Appeals to assist in resolving complaints. The Ombudsman would also be responsible for publishing statistics regarding the appeals process.

Background on Medicare Audit and Appeals Process

The Medicare Audit and Appeals Process allows providers and individuals who are dissatisfied with Medicare decisions about benefits or eligibility to have a hearing in front of an ALJ. There are five levels in the Medicare appeals process at which a beneficiary can challenge a prior decision before proceeding to a higher level decision-maker. Currently, Medicare's Recovery Audit (RAC) program is also facing significant delays, and the program has been in flux since last year. After a five-month hiatus, the program restarted some reviews in August 2014, but only on a limited basis. There has also been a significant delay in awarding new auditor contracts, adding to the uncertainty and criticism surrounding the program.

Polsinelli will continue to monitor the status of the proposed reforms. In addition, Polsinelli's experience in advising and representing clients throughout the Medicare Audit and Appeals Process will be valuable to providers as the legislation evolves.

For More Information

For questions regarding the content of this alert, please contact:

  

 
 

  

     

  

 
         

 

 

 

  

     

  

 
 

Atlanta  Chattanooga  Chicago  Dallas  Denver  Kansas City  Los Angeles  Nashville  New York
Overland Park  Phoenix  Raleigh  St. Joseph  St. Louis  San Francisco  Springfield  Washington, D.C.  Wilmington
polsinelli.com

 
 

  

     

  

 
 

  

ABOUT POLSINELLI

real challenges. real answers.SM  
Polsinelli is an Am Law 100 firm with more than 750 attorneys in 18 offices, serving corporations, institutions, entrepreneurs and individuals nationally. Ranked in the top five percent of law firms for client service and top five percent of firms for innovating new and valuable services*, the firm has risen more than 100 spots in Am Law's annual firm ranking over the past six years. Polsinelli attorneys provide practical legal counsel infused with business insight, and focus on health care, financial services, real estate, life sciences and technology, and business litigation. Polsinelli attorneys have depth of experience in 100 service areas and 70 industries. The firm can be found online at www.polsinelli.com. Polsinelli PC. In California, Polsinelli LLP.

* BTI Client Service A-Team 2015 and BTI Brand Elite 2015

  

 
 

  

     

  

 
 

Polsinelli provides this material for informational purposes only. The material provided herein is general and is not intended to be legal advice. Polsinelli is very proud of the results we obtain for our clients, but you should know that past results do not guarantee future results; that every case is different and must be judged on its own merits; and that the choice of a lawyer is an important decision and should not be based solely upon advertisements.

Copyright © 2015 Polsinelli PC.

 
             
Connect with us on LinkedIn. Connection with us on Twitter. Connect with us on Facebook. Polsinelli Health Care Health Care