Posted on Friday, October 5, 2018 1:33 PM
Medicare law requires providers to have a hearing and decision from an Administrative Law Judge (ALJ) within 90 days of request. If the decision is not rendered consistent with that standard, the appellant can accelerate the appeal to the next level. In recent years ALJ appeals have been increasingly backlogged with an expected delay of, minimally, two to three years before matters are scheduled and heard.
Earlier this year, CMS launched a Low Volume Appeals (LVA) process to allow providers whose appeals are validated to received 62% of the approved Medicare amount. CMS also introduced Settlement Conference Facilitation Process for larger appeals. “The National Association for Home Care & Hospice (NAHC) recently secured data reflective of scope and timeliness of appeals resolution at the ALJ level during 2016, 2017 and 2018 for home health and for hospice. The appeal load for home health is much higher than that of hospice, reflecting the longstanding issues related to the home health face-to-face requirements. The increase in the percentage of dismissed claims is the result of large settlements being processed (such as those addressed through the LVA and Settlement Conference Facilitation Process). When an appellant settles its claim with CMS, it withdraws its request for a hearing and this is reflected as a dismissal.”
Here is the data the NAHC collected:
PLEASE NOTE: The OMHA “year” follows the federal fiscal year, so data for 2018 is not complete.
|
Appeal Category: Home Health |
||||||
|
Decisions |
2016 |
% |
2017 |
% |
2018 |
% |
|
Favorable |
1,128 |
11.64% |
14.61% |
1.70% |
||
|
Partially Favorable |
3.89% |
3.24% |
0.17% |
|||
|
Unfavorable |
7,457 |
76.93% |
3,581 |
64.81% |
1,505 |
2.62% |
|
Dismissed |
7.54% |
17.34% |
54,875 |
95.51% |
||
|
TOTAL |
9,693 |
5,525 |
57,454 |
|
Appeal Category: Hospice |
||||||
|
Decisions |
2016 |
% |
2017 |
% |
2018 |
% |
|
Favorable |
50.94% |
51.91% |
26.46% |
|||
|
Partially Favorable |
3.76% |
0.53% |
0.58% |
|||
|
Unfavorable |
29.44% |
31.30% |
15.52% |
|||
|
Dismissed |
15.87% |
16.26% |
57.43% |
|||
|
TOTAL |
1,310 |
1,372 |
Report run date: Aug. 31, 2018
Source: NAHC Report
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