Final Rule: Changes to the Medicare Claims Appeals Procedures

Final Rule: Changes to the Medicare Claims Appeals Procedures
When Medicare makes a coverage or payment determination under Parts A, B, C, or D, involved parties, based on specific procedures, have the right to appeal the decision through 4 levels of Administrative Review:
  1. Redetermination Appeal: Decision made by the Medicare Administrative Contractor (MAC).
  2. Reconsideration Appeal: Decision made by the Qualified Independent Contractor (QIC).
  3. The Office of Medicare Hearings & Appeals (OMHA): Decision made by an Administrative Law Judge.
  4. The Medicare Appeals Council (also MAC): Decision made by an Administrative Appeals Judge.
The Final Rule addressing changes to the appeals processes noted above will take effect on July 8, 2019. In most instances, the changes remove, revise, and/or relocate language, rather than change the actual steps or procedures.
According to CMS
  • These changes will help to streamline the appeals process and reduce administrative burden on providers, suppliers, beneficiaries and appeal adjudicators.
  • These revisions, which include technical corrections, will also help to ensure the regulations are clearly organized and written to give participants a better understanding of the appeals process.
  • More than 284,000 appeal requests are dismissed each year because signatures are missing…. “These changes alone could save almost $11.8 million in costs for administrative and independent contractors who handle appeals.”
Key Elements of the Final Rule
Removal of the Requirement that Appellants Sign Appeal Requests
  • To promote consistency across appeal request requirements at each level, and to make the appeals process easier to understand, appellants no longer have to sign appeal requests.
  • This would allow adjudicators to review requests and focus on the merits of the appeal, rather than having to dismiss an appeal that is potentially meritorious.
Changes to the Time Frame for Vacating a Dismissal
  • This time frame will now be addressed in calendar days (180 days), not months (6) and will be in line with other time limited procedural actions such as filing of appeals, adjudication periods, and re-openings.
  • It will allow more consistency and predictability for appellants and adjudicators, as not all months have the same number of days.
Changes to Enhance Implementation of Rule Streamlining the Medicare Appeals Procedure
Overpayments – The Amount in Controversy (AIC)
  •  For the purposes of determining if an appeal meets the minimum AIC for an ALJ Hearing or Judicial Review, the amount has to reflect identified overpayments noted in the demand letter which include other payment or billing revisions, as well as appeals involving estimated overpayments that were not subsequently revised. Changes in the text will ensure both scenarios are accounted for.
Notice of Hearing
  • Must be sent to all parties that filed an appeal, participated in the reconsideration, the QIC that issued the reconsideration and/or another contractor, as well as CMS.
  • Written notice to participate or intent to participate in an ALJ hearing must be submitted no later than 10 calendar days after receipt of notice, and must also account for escalated requests for reconsideration.
The complete Final Rule may be found here in the Federal Register.