GAO proposes HHS do more to reduce Medicare appeals

HHS should take more steps to improve its oversight of the Medicare fee-for-service appeals process and to reduce the increased volume of appeals, the Government Accountability Office said in a report issued Thursday.

The report, requested by leaders of the Senate Finance Committee, examines trends in appeals for fiscal years 2010 through 2014; data HHS uses to monitor the appeals process; and HHS' efforts to reduce the number of appeals filed and backlogged. For the report, the GAO analyzed data from the three data systems used to monitor appeals, reviewed relevant HHS agency documentation and policies, federal internal control standards, and interviewed HHS agency officials and others.

The third appeal level, in which administrative law judges hear the appeal, experienced a 936 percent increase in filed appeals — from 41,733 to 432,534 appeals — from FY 2010 through FY 2014, the GAO found. This was largely driven by appeals of hospital and other inpatient stays, which increased more than 2,000 percent from 12,938 appeals in FY 2010 to 275,791 appeals in FY 2014.

The GAO also found that the number of appeal decisions issued after statutory time frames at the first four levels of appeals generally increased over the time period, with the largest increase in and largest proportion of late decisions occurring at the third and fourth levels.

"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."

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.

HHS said it generally agrees with the four recommendations from the GAO.


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