An overwhelming number of Medicare providers and beneficiaries questioning their Medicare claims are waiting -- and waiting -- for a decision. The U.S. Government Accountability Office released a report in June that details a massive increase in the number of Medicare appeals as well as wait times to get those appeals resolved.
The Medicare appeals process has four stages, and GAO investigators found increases in appeals filed at each one, including a 62 percent rise at the first level from 2010 through 2014 and a ten-fold increase in third-level appeals during the same time period.
Appeals filed at the third stage are heard by an administrative law judge who is required to issue a decision within 90 days from the time a hearing is requested. But the average wait it took for an appeals decision in the first half of fiscal 2016 was 819 days, up from 94 days in fiscal 2009, according to data from the Office of Medicare Hearings and Appeals.
Also in June, the Department of Health and Human Services, which oversees Medicare, responded to complaints about the backlog with several proposed changes including legislative reforms that would provide additional funding and new authorities to address the growing volume of appeals. In addition, a bill approved by the Senate Finance Committee would make several changes to the system, including establishing a voluntary dispute-resolution process.
In the meantime, what can you do to avoid this mess if you or a loved one needs to file an appeal?
Understand the problem. The vast majority of appeals are filed by health care providers, including hospitals and doctors. One reason for the jump in appeals is a program known as recovery audits, in which hospital payment records are inspected for errors. The audits have caused a large number of the appeals.
In an effort to avoid individual patients getting caught in the provider backlogs, Medicare started putting patients ahead of providers in 2014, allowing their appeals to be considered first.
Unfortunately, that hasn't eliminated the long waits, said Alice Bers, attorney for the Center for Medicare Advocacy. Bers recently reached a preliminary settlement with Health and Human Services in a class action representing Medicare beneficiaries who waited anywhere from 120 days to a year-and-a-half for an appeals decision. One plaintiff who was appealing his nursing home claim died the day before a favorable decision arrived. The terms of the settlement, which Bers expects to be finalized in August, should make it easier for Medicare beneficiaries to avoid the long waits.
Be patient. You must go through the first two levels of Medicare appeals before you can request an administrative hearing with a judge. The first two levels almost always end in a denial, said Bers. Don't get frustrated or become intimidated with the process at this stage, she advises. You want to be sure to get in front of a judge.
Identify yourself clearly. When you do request a hearing, it's extremely important to clearly identify yourself as a Medicare beneficiary so you get moved to the front of the line. "It seems so simple, but it's the biggest reason consumers get lost in the fray," Ber said.
Write "Attn: Beneficiary Mail Stop" as part of the address on the envelope, and also clearly identify yourself as a beneficiary at the top of your letter requesting a hearing. "Hopefully, with some of the proposed changes this process will get easier," Ber said. "But for now you've got to pay attention to the details."