CMS and Congress may eliminate the administrative law judge level for appeals of Medicare claims reviews, and that measure could have a major impact on hospitals and other providers, according to a recent blog post by Karen Bowden, senior vice president of Craneware.
There are four general levels of appeal: Level One goes to CMS Medicare Administrative Contractors, Level Two goes to CMS Qualified Independent Contractors, Level Three goes to ALJs and Level Four goes to the Medicare Appeals Council. The ALJ level is the most common platform of the four.
Ms. Bowden wrote that she first heard about the possibility of the ALJ level being eliminated from the Medicare appeals process at a conference. She then encountered an article from the Center for Medicare Advocacy, which said CMS had commenced discussions with members of Congress to eliminate the ALJ level. According to the article, CMS' reason for potentially eliminating the ALJ step is the "backlog of ALJ cases," among others.
Ms. Bowden said "any effort to eliminate ALJ hearings is a step in the wrong direction" because the ALJ level gives providers an arena to formulate a defense against Recovery Auditor (RAC) overpayment reviews.
Recently, a study from the HHS Office of Inspector General found that hospitals and other Medicare providers filed 85 percent of payment appeals at the ALJ level, 56 percent of which went in favor of providers, and the OIG concluded that serious improvements are needed to clarify Medicare policies.
There are four general levels of appeal: Level One goes to CMS Medicare Administrative Contractors, Level Two goes to CMS Qualified Independent Contractors, Level Three goes to ALJs and Level Four goes to the Medicare Appeals Council. The ALJ level is the most common platform of the four.
Ms. Bowden wrote that she first heard about the possibility of the ALJ level being eliminated from the Medicare appeals process at a conference. She then encountered an article from the Center for Medicare Advocacy, which said CMS had commenced discussions with members of Congress to eliminate the ALJ level. According to the article, CMS' reason for potentially eliminating the ALJ step is the "backlog of ALJ cases," among others.
Ms. Bowden said "any effort to eliminate ALJ hearings is a step in the wrong direction" because the ALJ level gives providers an arena to formulate a defense against Recovery Auditor (RAC) overpayment reviews.
Recently, a study from the HHS Office of Inspector General found that hospitals and other Medicare providers filed 85 percent of payment appeals at the ALJ level, 56 percent of which went in favor of providers, and the OIG concluded that serious improvements are needed to clarify Medicare policies.
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