News: Court orders Medicare appeal backlog cleared by 2020

In the latest twist of the ongoing saga of Medicare claims denials and appeals, the U.S. District Court for the District of Columbia ordered Medicare must clear its backlog, which currently approaches one million claims, HealthLeaders Media reported.

“Plaintiffs sought relief from a morass in which hundreds of thousands of appeals were languishing in a highly backlogged administrative process,” Judge James Boasberg wrote in his December 5 opinion.

The court ordered CMS to reduce the backlog of cases by:

• 30% by Dec. 31, 2017
• 60% by Dec. 31, 2018
• 90% by Dec. 31, 2019
• 100% by Dec. 31, 2020

It also asked for status reports every 90 days, according to an article from AHANewsNow. The American Hospital Association, which sued Health and Human Services Secretary Sylvia Burwell in 2014 over the appeals backlog, said the ruling should not only tame the backlog but also Medicare's Recovery Audit Contractors.

“To meet the court-ordered backlog reductions, we trust that [CMS] will implement real reforms critical to resolving the backlog, including fundamental reforms of the Recovery Audit Contractor program,” AHA General Counsel Melinda Hatton said, calling the decision “a victory” for facilities struggling to mitigate losses and navigate “a heavily backlogged appeals system.”

CMS held a MLNConnects National Provider Call on Monday, December 12, to review its administrative settlement process regarding outstanding inpatient status claims appeals. CMS will follow a process similar to that employed in 2014. Hospitals stand to receive 66% of the net payable amount of denied inpatient claims on the contingency that it agree to dismiss all associated appeals and both entities accept the settlement as final administrative and legal resolution of eligible claims, according to slides from the call. (The recording of the call should be available within two weeks of the live call, CMS says.)

Claims eligible for the settlement process include those:

• Denied by a MAC, RAC, CERT, OIG, or ZPIC for Fee-for-Service Medicare
• Denied based on “patient status”
• Date of Admission prior to 10/1/2013

Additionally, the hospital must have submitted a timely appeal to the denial, not exhausted its appeal rights, and not have received payment for the service as a Part B claim.