The Senate Finance Committee has approved by voice vote a bipartisan proposal to reform the Medicare audit and appeals process in an attempt to ease the backlog of Medicare appeals and promote efficiency and transparency. After the voice vote, which took place on June 3, Senator Ron Wyden (D-Oregon), the ranking member of the committee, announced the key points of the draft proposal, called Audit & Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015, which include rewarding providers who consistently bill correctly by exempting them from some audits.
According to Wyden, the bill would give the U.S. Department of Health and Human Services (HHS) the resources it needs to keep up with the enormous increase in appeals. Chief Administrative Law Judge (ALJ) Nancy Griswold of the Office of Medicare Hearings and Appeals (OMHA) told the committee her office can currently adjudicate 77,000 appeals in a year; OMHA received 474,000 appeals in 2014. The bill would also create a new track for lower-cost, less-complex cases to be considered by a different set of hearing officers, allowing HHS to use its resources more efficiently and process more appeals. Passage of the bill will also require the Centers for Medicare & Medicaid Services (CMS) to better coordinate provider audits to ensure the entire process is more transparent and efficient, and create an ombudsman position at CMS.
“Here’s the bottom line: This legislation will streamline the appeals and audits process so cases are resolved quickly and at the earliest possible step,” said Wyden in the announcement. “And it’s important to remember that behind each case is a patient paying out-of-pocket while their appeal is being considered, or a provider who would rather focus on giving care than dealing with billing issues. And HHS is also working diligently to ensure taxpayer dollars are being spent as efficiently as possible.”
Additional details of the bill, according to the Reed Smith Health Industry Washington Watch, include provisions to:
- Raise the amount in controversy threshold for review by an ALJ and establish a new Medicare Magistrates program within OMHA to review cases with lower costs.
- Require Qualified Independent Contractors (QICs), Medicare Magistrates, ALJs, or the Departmental Appeals Board (DAB) to remand an appeal to the Medicare Administrative Contractor (MAC) for a redetermination when the appellant introduces new evidence into the administrative record at a subsequent level of appeal (with certain exceptions).
- Require the HHS secretary to establish a process whereby ALJs and Medicare Magistrates could issue decisions based on the evidence of record without holding a hearing when there are no material issues of fact in dispute and the ALJ or the Medicare Magistrate determines that there is a binding authority that controls the decision in the matter under review.
- Establish a voluntary alternative dispute resolution process to allow multiple pending claims with similar issues of law or fact to be settled as a unit, rather than as individual appeals, in certain circumstances.
- Allow for the use of sampling and extrapolation, with the appellant’s consent, to expedite the appeals process.
- Require the secretary to implement a process by which OMHA and the DAB would refer credible suspicion of fraudulent activity to appropriate law enforcement entities and CMS.
- Require OMHA to conduct annual training for all ALJs and Medicare Magistrates on Medicare policies. HHS would be required to ensure that review entity contractors consistently apply Medicare payment and coverage policies, and that conflicting local and national coverage determinations and program instructions are appropriately modified.
- Increase the transparency of the appeal process by publishing data regarding the number of determinations appealed, outcomes, and aggregate appeal statistics for each contractor and provider type.
- Require HHS to develop a comprehensive strategy for claims review determinations made on a prepayment, post-payment, or prior-authorization basis, focusing on identifying and reducing high-impact claim errors.
- Prohibit Recovery Audit Contractors (RACs) from conducting patient status reviews more than six months after the date of service if the claim was submitted within three months of the date of service, and direct the secretary to study the impact of shortening the look-back period for other RAC audits.
To watch a video of the Senate Finance Committee voice vote proceedings, visit www.finance.senate.gov.