Feds prioritize beneficiary hearings, postpone provider appeals

The Office of Medicare Hearings and Appeals (OMHA) suspended work on new hearing requests from healthcare providers to clear a backlog of about 357,000 pending beneficiary appeals, according to reports by McKnight's Long-Term Care News and The Washington Post. OMHA announced its inventory reduction plan in a memorandum from Chief Administrative Law Judge Nancy J. Griswold last month.

Beneficiary appeal requests grew by about 184 percent from 2010 to 2013, the Post noted, with no corresponding administrative resource increase to manage them. OMHA received 1,250 appeals weekly in January 2012, but that volume climbed to more than 15,000 per week as of November, overwhelming the 65 administrative law judges and their employees responsible for the work.

"Because they are among out nation's most vulnerable populations, OMHA is committed to being as responsive as possible to the Medicare beneficiary community, regardless of the challenges presented by the significant increase in the number of requests being filed," Griswold said in an email to the Post.

The average wait time for beneficiary appeal hearings now has reached 16 months, the memorandum stated. Some appellants have died before their cases were heard.

Beneficiary appeals often challenge insurers' reaffirmed denials of payment for home care, nursing home services, ambulance travel and other benefits, the Post noted. A 2012 investigation by the U.S. Department of Health & Human Services found administrative law judges reversed prior denials 28 percent of the time in third-level beneficiary appeals.

But shelving provider requests for about two years to improve beneficiary service has angered hospitals, many of which have historically prevailed in third-level appeals, as FierceHealthcare previously reported.

The American Hospital Association claimed OMHA's suspension violates the Medicare statute requiring administrative law judges to render decisions within 90 days of receiving a hearing request, McKnight's reported. Medicare recovery audit contractors contribute to the appeals backlog by issuing "excessive inappropriate denials," AHA Executive Vice President Rick Pollack said in a Jan. 14 letter to government officials. He has asked OMHA and the Centers for Medicare & Medicaid Services to solve this problem.

For more:
- read the Washington Post article
- here's the OMHA memorandum (.pdf)
- see the McKnight's article