Medicare appeals backlog persists, GAO says

Gavel and books

The backlog of Medicare appeals continues to persist despite the best efforts of federal officials, according to a new report from the Government Accountability Office.

When a provider or patient files an appeal for a denied Medicare fee-for-service (FFS) claim, the appeal goes through four levels of review within the U.S. Department of Health and Human Services, and the final stage by federal courts, says GAO. For its report, the agency examined HHS data from fiscal year 2010 to 2014 relating to FFS claims including number of claims processed and HHS’ efforts to reduce the appeal backlog.

While the Centers for Medicare & Medicaid Services paid out a portion of the claims in 2014, GAO says that the backlog “outpaces the adjudication process and will likely persist,” and found the largest increase of appeals filed in levels three and four of the process.

Part of the issue is that repetitious claims aren’t bundled, and if HHS finds in favor in the appellant for one claim, repetitive claims still must go through the process. GAO recommends HHS find a solution to deal with repetitive appeals that involves major consolidation.

GAO also says that HHS needs to have better oversight of the appeals process to reduce the backlog, and needs to get a better handle on its data systems. Without accurate data on its own appeals and processes, HHS won’t have the tools to cut the backlog.

A previous report from GAO found that half of all appealed claims get reversed. Most claim rejections are due to missing information or simple billing errors, according to that report.

To learn more:
- download the GAO report (.pdf)