Hospitals Can Get Partial Payment for Medicare Appeals

When hospitals appeal a claim denial by CMS, the wait time for a decision currently averages 489 days compared to the 90 days required by law. Both the American Hospital Association and the Center for Medicare Advocacy have filed lawsuits to compel the Secretary of Health and Human Services to meet statutory deadlines for reviewing the Medicare denials. CMS now is offering an administrative agreement to any acute care or critical access hospital that agrees to resolve its pending appeals (or waive its right to request an appeal) in exchange for a partial payment of 68 percent of the net payable amount.


A Medicare Learning Network eNews brief noted “CMS encourages hospitals with patient status claim denials currently in the appeals process to make use of this administrative agreement to alleviate the burden of current appeals on both the hospital and Medicare system.” (“CMS Offers Settlement to Acute Care Hospitals and CAHs to Resolve Appeals of Patient Status Denials,” MLS Connects Provider eNews, August 29, 2014)


The growing backlog of Medicare appeals has been the subject of recent congressional oversight and lawsuits. A CMS administrative law judge told lawmakers in July that the Office of Medicare Hearings and Appeals (OMHA) has experienced a 545 percent increase in appeals from 2011 to 2013. Late last year, OMHA suspended assignment of most new requests for hearings for at least two years because of the Medicare appeals backlog. (“CMS Offers Partial Payment to Hospitals to Lessen Medicare Appeals Backlog,” Health Lawyers Weekly, September 5, 2014)




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