A new proposed rule from HHS attempts to clear some deadwood from the third and fourth level of Medicare appeals and reduce the absurd backlog at those levels.
The rule mainly but not entirely deals with appeals at the administrative law judge (ALJ) level, generally the choice when the first and second redetermination and reconciliation levels of appeal have been exhausted, and at the next level, the Medicare Appeals Council. These levels are administered by HHS's Office of Medicare Hearings and Appeals (OMHA).
The backlog in Medicare appeals at the ALJ level is huge; OMHA reports that as of the end of FY 2015, 884,017 appeals were waiting to be adjudicated by ALJs, and 14,874 appeals waiting for the Council.
The most sweeping change is that some Medicare Appeals Council decisions will be established as "precedential" -- meaning they will be published as guidance for decisions on cases with similar particulars.
"In the limited circumstances in which a precedential decision would apply to a factual question, the decision would be binding where the relevant facts are the same and evidence is presented that the underlying factual circumstances have not changed since the Council issued the precedential final decision," says the rule.
The rule would also allow "attorney adjudicators" to decide certain ALJ-level cases and appeals, which "would allow ALJs to focus their efforts on conducting hearings and adjudicating the merits of more complex cases," per HHS' press release.
Also, the rule would reduce the number of parties allowed to participate in some appeals, allow ALJ telephone hearings, and institute a number of other innovations and efficiencies.
The rule is under public review through 5 p.m. on August 29th. Follow Part B News for more details.