Audit & Appeal Fairness, Integrity and Reforms in Medicare Act of 2015 (“AFIRM Act”)

On June 3, the Senate Finance Committee approved the Audit & Appeal Fairness, Integrity and Reforms in Medicare Act of 2015 (“AFIRM Act”). The bill aims to expedite the Medicare appeals process by streamlining certain appeals functions and increasing funding for the Office of Medicare Hearings and Appeals (OMHA) and the Departmental Appeals Board (DAB), the third and fourth levels of the Medicare appeals process. The legislation was reported out of the Committee by a voice vote, and now heads to the Senate floor.

The bill includes several provisions that are intended to address the appeals backlog, such as:

  • Raising the amount in controversy threshold for Medicare appealed claims heard by an ALJ
  • Establishing a new category of officials within OMHA, Medicare Magistrates
  • Allowing a reviewing entity to consolidate pending requests.
  • Allowing an adjudicator to use statistical sampling and extrapolation
  • Requiring a QIC, a Medicare Magistrate, an ALJ or the DAB to remand an appeal to the MAC for a redetermination when the appellant introduces new evidence
  • Allowing an ALJ or Magistrate to issue decisions, based on the evidence of record, without holding a hearing when there are no material issues of fact
  • Requiring HHS to establish a process by which an appeal before an ALJ can be certified for expedited access to judicial review
  • Requiring the Secretary of HHS to establish alternative dispute resolution processes, including mediation

The bill also includes several policies that are intended to improve the review and appeals processes, such as requiring the Secretary to:

  • Establish a CMS Ombudsman for Medicare Reviews and Appeals, who would help resolve complaints and inquiries involving the Medicare review or appeals processes
  • Designate a point of contact to coordinate, oversee and perform several tasks to improve the review process.
  • Exempt from audits certain providers with low error rates for claims subject to additional documentation requests.
  • Adjust the number of medical records a reviewing entity can request from a provider or supplier
  • Review guidelines and methods prior to their use in the review of any claims paid by Medicare.
  • Prohibit RAs from conducting patient status reviews more than 6 months after the date of service if the claim was submitted within 3 months of the date of service.
  • Study the potential burden of the look-back period under current law as well as the impact of shortening the look-back
  • Submit recommendations to Congress on how to change the current RA payment structure from an incentive-based model to a non-incentive based approach without additional financial burdens on providers.

Courtesy of NASL