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  • Washington Highlights

    CMS Implements AAMC’s Recommendation to Address Appeals Backlog in Final Rule

    Len Marquez, Senior Director, Government Relations

    The Centers for Medicare and Medicaid Services (CMS) Jan. 13 released the Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures final rule, which is designed to address the overwhelming backlog of pending Medicare appeals.

    In its comment letter, the AAMC recommended that the Office of Medicare Hearings and Appeals (OMHA) compile a yearly report to assess the impact of decisions issued by attorney adjudicators on the backlog, including the percentage of decisions decided in favor of the government. CMS agreed with AAMC’s recommendation, stating that the disposition data on OMHA’s website will be expanded to include data for attorney adjudicators to assess the impact of decisions on the overall appeals backlog.

    Additionally, CMS finalized the effect of decisions issued by the Departmental Appeals Board (DAB) Chair, affirming that it would provide more consistency in decisions at all levels of the appeals process, as well as provide clarity to appellants and adjudicators.

    CMS also finalized the proposal that grants attorney adjudicators broader authority to (1) decide appeals for decisions that can be issued without a hearing, (2) review dismissals issued by a Qualified Independent Contractor (QIC), (3) issue remands to CMS contractors, and (4) dismiss requests for hearings when an appellant withdraws a request.