On 1/17/17, the Department of Health and Human Services (HHS) issued a final rule to improve the Medicare Appeals Process and assist in decreasing the significant backlog of appeals at the Office of Medicare Hearings and Appeals (OMHA) - the Administrative Law Judge (ALJ), the 3rd level of appeal - and the Departmental Appeals Board (DAB) - Medicare Appeals Council (MAC), the 4th level of appeal.
The final rule encompasses several changes with emphasis on the ALJ and the MAC level of appeals. These are as follows:
- Decisions by the MAC (4th level of appeal) may be designated as precedent to allow decision consistency at all levels of appeal
- Attorney adjudicators will be utilized to expand the OMHA resource pool at the ALJ level. These adjudicators will be utilized to address appeals decided on the record, dismissal reviews, contractor remands, and dismissal requests for appellant withdrawn cases.
- CMS or CMS contractor hearing participants at ALJ will be limited. CMS and its contractors will still be allowed to submit position papers and written testimony, or serve as a witness.
- Regulations will be clarified to avoid unnecessary furtherance of appeals to the MAC (4th level of appeal)
- Efficiencies will be developed through the elimination of superfluous steps, the consolidation of procedures, and a provision for appellants to furnish specific information on what they are appealing and who will attend the hearing.
- Areas for improvement will be addressed, including items already identified by stakeholders, which would improve the process and response to customers. For example, establishing adjudication time frames for cases remanded to the MAC (4th level of appeal), revision of remand rules, streamlining of the escalation process, and concise rules on good cause for new evidence at the ALJ.
In addition, the Fiscal Year (FY) 2017 Presidential Budget includes additional funding for both OMHA and the DAB to better align disposition capacity and volume. The budget includes legislation to assist HHS in processing a larger number of appeals and resolving appeals at lower levels so they do not reach OMHA or the DAB.
The final rule in conjunction with the FY 2017 Presidential Budget are estimated to eliminate the backlog of appeals at the higher levels by FY 2020.
As always, Trinity Rehab Services will continue to address appeals within the guidelines set-forth by HHS and federal regulations.