The American Hospital Association isn't pleased with a federal proposal to streamline the amount of time it takes to appeal claim denials in administrative law courts.
In a recent letter (.pdf) to the Office of Medicare Hearings and Appeals Chief Administrative Judge Nancy J. Griswold , the AHA said that the proposal--which includes increased funding at all levels of the appeals process and more encouragement of the parties to settle cases earlier--only “scratches the surface” of the problem.
The AHA noted that given the average appeals processing time was 935.4 days in the third quarter of fiscal year 2016--up 75 days from the second quarter and 140 days since the start of the fiscal year--the government must consider more robust actions.
“If the proposals in this rule and proposed funding increases and other administrative changes in the president’s fiscal year 2017 budget are implemented, the agency may achieve the elimination of the appeals backlog--by 2021,” wrote Ashley Thompson, the AHA's senior vice president of public policy analysis and development. “This projection is striking because it signals to providers with claims already delayed in the appeals process that they may expect to wait five more years before these claims can be resolved.”
A study published last year suggested that the appeals process of claims reversed by Medicare recovery auditor contractors (RACs) is a burden for hospitals, requiring many employees to handle. The Centers for Medicare & Medicaid Services has already taken some measures to streamline the number of claims, such as offering last year 68 cents on the dollar--or $1.3 billion--to hospitals to settle a backlog of disputed claims for short-term hospital stays. But CMS has also been criticized for lax oversight of claims and RAC management.
Instead, the AHA proposed that hospitals be allowed to keep payments in dispute until the case has been decided by an administrative law judge--the third in a five-step appeals process--and that any interest added to a payment does not accrue until the judge makes his or her decision.
It also proposed that the government lift the one-year limit on refiling denied Part A inpatient claims as a Part B outpatient claim; and limit what RACs can review to a particular, defined time period instead of approving them indefinitely. It suggests that after the issue's audit time period has run out, RACs would stop auditing that issue. CMS would then analyze the audit results and provide education to providers...if warranted.
The AHA also asked that if attorney adjudicators are used to address disputes that don't require an administrative law judge, that they have knowledge and experience applying Medicare regulations.