News: GAO recommends HHS take steps to reduce Medicare appeals

The Government Accountability Office (GAO) says the Department of Health and Human Services (HHS) should take steps to reduce the number of Medicare appeals and strengthen oversight of the appeals process, according to a report released by the GAO on June 9.

The GAO studied trends and HHS efforts to reduce the number of appeals for fiscal years 2010 through 2014, using HHS data . During the review period, the total number of filed appeals at Levels 1 through 4 increased significantly but varied by level. Level 3 experienced the largest increase—from 41,733 to 432,534 appeals (936%)—during this period.

Medicare appeals process consists of four administrative levels within HHS, and a fifth reviewed by federal courts. Appeals are generally reviewed by each level sequentially, as appellants may appeal a decision to the next level depending on the prior outcome. Separate appeals bodies review appeals and issue decisions under time limits established by law, which vary by level.

The GAO recommended that HHS take four actions, including improving the completeness and consistency of the data used by HHS to monitor appeals and implementing a more efficient method of handling appeals associated with repetitious claims.

“Without more reliable and consistent information, HHS will continue to lack the ability to identify issues and policies contributing to the appeals backlog, as well as measure the funds tied up in the appeals process,” the report concludes. “Finally, the manner in which appeals of certain repetitive claims are adjudicated is inefficient, which leads to more appeals in the system than necessary.”