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Welcome to Global Integrated Reimbursement Services’ blog. The purpose of our blog is to allow access to a repository of issues that our company tracks regarding the reimbursement for pharmaceuticals, medical devices, diagnostics, biologics, and biosimilars. Also, it shows you how we can assist you in these areas.

Elimination of Medicare Appeals Backlog Ordered by 2020

A federal judge recently decided that the Secretary of Health and Human Services (HHS) must eliminate the Medicare appeals backlog currently pending before Administrative Law Judges (ALJs) by Dec. 31, 2020.

An appeal is the action a Medicare beneficiary or healthcare provider can take if they disagree with a coverage or payment decision made by Medicare, a Medicare health plan, or a Medicare Prescription Drug Plan. The appeals process has 5 levels; If one disagrees with the decision made at any level of the process, they can generally go to the next level. Once a level 3 appeal is filed with the ALJs, by law, the court has 90 days to make a decision.

Over the past several years, those level 3 reviews have become increasingly delayed due to volume. HHS reported that appeal hearings at the ALJ level were now, on average, held for 935.4 days, which is over ten times greater than the 90-day statutory limit.

The court’s ruling is a victory the lead plaintiff, the American Hospital Association (AHA), and three of its member hospitals who have long contested HHS’s failure to render ALJ decisions within the prescribed statutory deadline. “Today’s decision is a victory for hospitals that continue to have billions of dollars in Medicare reimbursement tied up in a heavily backlogged appeals system,” stated Melinda Hatton, general counsel of the American Hospital Association

HHS must abide by a timetable for reducing the backlog and provide the court with a status update every 90 days. The timetable requires an initial 30% decrease in current backlogged claims volume by Dec. 31, 2017 and ends with complete elimination of cases pending before ALJs by Dec. 31, 2020. If HHS fails to meet the deadlines, an unspecified default judgment may be granted in favor of those issuing the claims denial appeal, potentially as soon as Jan. 1, 2021.

We can assist you with all level of appeals through our reimbursement experts and reimbursement lawyers. More importantly, we can help your accounts to prevent denials in the future by utilizing our InContact Reimbursement HotlineTM Services. Please contact us to learn more.