Backlog Slows Medicare Appeals Process for Hospitals, Physicians

A 10-fold jump in Medicare payment appeals since 2009 has “clogged and overwhelmed” the Recovery Audit system, says a Florida-based rheumatologist who has testified before Congress on the process.¹ The Recovery Audit Program’s stated mission is “to identify and correct improper [Medicare] payments through the efficient detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries, and the identification of underpayments to providers.”²

Hospitals report appealing 50% of all claims.³

The “backlog is huge, and it’s not just hospitals; it’s practitioners, too,” says Michael Schweitz, MD, FACP, who has practiced for 37 years at Arthritis and Rheumatology Associates of Palm Beach in West Palm Beach, Fla. “This backlog is affecting routine appeals that private practices go through. Typically, such appeals are adjudicated in 60 to 90 days, [but] now are taking much longer. It can cause significant cash-flow problems at the practice level, not just the hospital level.”

The increase in appeals has jammed up the process so much that hospital systems are joining together to sue the U.S. Department of Health and Human Services (HHS), and even Congressional lawmakers have criticized the program’s effectiveness.

According to HHS, appeals to their Office of Medicare Hearings and Appeals’ administrative courts program have spiked to 384,151 in 2013 from just 35,831 appeals in 2009, before the launch of the Recovery Audit Program.¹ The wait time for decisions on routine appeals can be as long as five years, according to the HHS, and the average processing time for appeals decided in fiscal year 2014 is 387 days.¹ As a result of the backlog, HHS’ administrative law judges have implemented a two-year moratorium on docketing Medicare appeals received after April 1, 2013.¹

Recently, three hospitals and the American Hospital Association filed a federal lawsuit seeking to force HHS to meet its statutory requirement to decide appeals within 90 days.

“If you are seeing this many appeals clogging the system, then something is wrong with the process,” says Dr. Schweitz, who previously served on the ACR’s Committee for Rheumatologic Care and is the president of the Coalition of State Rheumatology Organizations. “I think the volume of appeals speaks directly to the issues with the system.” (posted 7/11/14)

Richard Quinn is a freelance writer in New Jersey.

References
1. Department of Health & Human Services (HHS). Office of Medicare Hearings and Appeals. http://www.hhs.gov/omha/important_notice_regarding_adjudication_timeframes.html. Updated July 7, 2014. Accessed July 10, 2014.

2. Centers for Medicare & Medicaid Services (CMS). Recovery Audit Program. http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/. Updated March 25, 2014. Accessed July 10, 2014.

3. AHA survey: Hospitals appealing half of RAC claim denials. AHA News Now. May 29, 2014. http://www.ahanews.com/ahanews/jsp/display.jsp?domain=AHANEWS&dcrpath=AHANEWS/AHANewsNowArticle/data/ann_052914_RACTrac. Accessed July 10, 2014.