52 Weeks’ Worth of ALJ Appeals Received Every 24 Weeks

Home > Articles > 52 Weeks’ Worth of ALJ Appeals Received Every 24 Weeks

The Office of Medicare Hearings and Appeals (OMHA) receives more than one year's worth of Administrative Law Judge (ALJ)-level appeals every 24 weeks, according to a new document by the U.S. Department of Health and Human Services (HHS). ALJ hearings are the third level of the audit claims appeal process. The Medicare Appeals Council, the fourth level of appeals, receives more than a year's worth of appeals work every ten weeks. As of the end of the fourth quarter of fiscal year 2016, the pending workload at the council exceeded 22,000 appeals, while annual adjudication capacity was about 2,600 appeals, HHS says. The Centers for Medicare & Medicaid Services (CMS) is currently meeting its statutory timeframes to process appeals at the first and second level of appeals, and is not experiencing a backlog. HHS has previously estimated that it can address about 92,000 claims annually, but the pending workload exceeded 650,000 appeals as of the end of the fourth quarter of fiscal year 2016.

A few companies generate a significant portion of the appeals backlog, according to the document. Four durable medical equipment (DME) companies and one state Medicaid agency filed 51 percent of appeals at the ALJ level in the first quarter of fiscal year 2015. Three DME companies filed 35 percent of the appeals at the second level of appeals in 2015 compared to 12 percent in 2012.

HHS says the current appeals structure encourages appeals to every claim because there is no filing fee and because the minimum amount in controversy required for an ALJ hearing is substantially lower than the amount required for judicial review, the fifth level. The 2017 amount in controversy is $160; the amount required for judicial review is currently $1,560.

HHS says it has a three-pronged approach to address the backlog and improve the system: invest new resources at all levels of appeal to increase adjudication capacity and implement new strategies to alleviate the current backlog; take administrative actions to reduce the number of pending appeals and encourage resolution of cases earlier in the process; and propose legislative reforms that provide additional funding and new authorities to address the appeals volume.

To read the document, visit "HHS Primer: The Medicare Appeals Process."