Changes Proposed to Medicare Appeals Process

CMS Tries to Pull a Fast One on the ALJ 90-Day Decision Deadline

Many O&P professionals and practices have experienced extensive Medicare contractor audits that required them to pursue the administrative appeals process, usually resulting in a hearing before an Administrative Law Judge (ALJ). With Recovery Audit Contractors (RACs) poised to ramp up activity, the need to pursue additional appeals will continue well into the future. RACs and the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have particularly focused on lower-limb prostheses and certain types of orthoses in the recent past. For the O&P professionals who have gone through this process in the past few years, the appeals backlog and resulting delay in securing final appeal decisions have become major sources of frustration.

It is apparent that the Medicare appeals process is severely flawed, with little hope of getting an appeal through the process in a reasonable time frame. The ALJ delay grows longer every day, and the increasing dissatisfaction and desperation on the part of providers and suppliers who are stuck in the system has reached fever pitch. Given the 750,000 cases in the ALJ backlog and the capacity of the Office of Medicare Hearings and Appeals (OMHA) to decide approximately 77,000 cases each year, the backlog could be as long as ten years at this point. With more cases coming into the system each day, the problem will only worsen unless major reforms are implemented. The Medicare statute requires ALJs to decide each appeal within 90 days, but OMHA reports that the average time it currently takes to get a case through the ALJ level of appeal is 832 days.