Judge: Medicare Appeals Backlog Must Be Cleared by 2021

In a victory to health care providers waiting on lengthy appeals decisions, a federal judge ordered the Department of Health and Human Services (HHS) to eliminate its backlog of Medicare appeals claims in the next few years. The order comes after a damning report revealed a shockingly large backlog of Medicare claims appeals cases, with many stemming from home health.

Health care providers that receive fee-for-service claims denials can appeal those decisions. Over the past few years, the number of appeals filed by health care providers has exploded. In 2015, 123 million Medicare fee-for-service claims were denied, of which 3% were appealed.

As a result of ballooning appeals claims and growing frustration among health care providers waiting for appeals to be processed, the American Hospital Association and other affiliated entities filed suit.


“The court’s final ruling may finally spur concrete action by the Centers for Medicare & Medicaid Services (CMS) to reduce what are wholly unreasonable delays in providing appeal rights to Medicare beneficiaries and providers of health services,” William Dombi, vice president for law at the National Association for Home Care and Hospice (NAHC), told Home Health Care News.

AHA commended the decision as a “victory” for hospitals.

HHS laid out a three-prong approach to take on the appeals backlog earlier this year that included new administrative actions, legislative reforms and new resources. However, the department said even with increased resources, it likely wouldn’t be able to eliminate backlog before 2021.


For the home health industry, which has faced an onslaught of new regulations over the last few years, a quick appeals process would be much-needed relief. However, larger reforms may be required to combat the high number of appeals at the front-end of the claims and auditing process, NAHC argues.

“Much of the increased appeals backlog is due to overzealous claims audits through Medicare,” Dombi said. “We hope that CMS recognizes that part of the solution lies in its reduction of unreasonable and arbitrary claim denials that force providers into an appeal just to obtain what they should be paid. Unless that occurs, the backlog in appeals will only increase in spite of the court’s order.”

Now, with the judge’s ruling, HHS must eliminate significant portions of backlogged appeals claims before the end of 2020.

HHS will have a timetable to reduce and eliminate backlog over the next few years:

—30% reduction of backlog cases December 31, 2017

—60% reduction in backlog by December 31, 2018

—90% reduction in backlog by December 31, 2019

—Elimination of backlog by December 31, 2020

Written by Amy Baxter

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