Strengthening Medicare for current and future generations

In recent years, an unprecedented increase in the number of Medicare appeals has led to a backlog of pending appeals at the Department of Health and Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA) and Department Appeals Board (DAB).

Today, we’re taking action to reduce the number of pending appeals and encourage the resolution of cases earlier in the Medicare appeals process. These actions, outlined in a final rule, expand the pool of available OMHA adjudicators; increase decision making consistency among the levels of appeal; and improve efficiency by streamlining the appeals process so less time is spent by adjudicators and parties on repetitive issues and procedural matters. The final rule also incorporates feedback from stakeholders, including strengthening the quality of the appeals process and our responsiveness to customers, and in particular benefits Medicare beneficiaries by clarifying processes and adding provisions for increased assistance when they are unrepresented.

HHS has updated its Primer on the Medicare Appeals process that describes its three-pronged strategy to address the backlog (https://www.hhs.gov/sites/default/files/omha/files/medicare-appeals-backlog.pdf):

1. Invest new resources at all levels of appeal to increase adjudication capacity and implement new strategies to alleviate the current backlog.
2. Take administrative actions to reduce the number of pending appeals and encourage resolution of cases earlier in the process.
3. Propose legislative reforms that provide additional funding and new authorities to address the appeals volume.

Today’s rule is part of the second prong of our strategy. It represents an important step under HHS’s comprehensive effort to address the appeals workload through every available administrative means under current statutory and budgetary authorities. But administrative actions alone won’t solve the backlog problem.

The fiscal year (FY) 2017 President’s Budget requested additional funding to bring our capacity for processing and resolving appeals in line with current appeal volume. The budget request also includes a comprehensive legislative package aimed at both helping HHS process a greater number of appeals and encouraging resolution of appeals earlier in the process before they reach the OMHA and the DAB.

With the administrative authorities set forth in this rule and the proposed funding increases and legislative actions outlined in the President’s Budget, we estimate that the backlog of appeals could be reduced to just 20,000 appeals by FY 2019 and eliminated by FY 2020.

We believe the changes in the rule will streamline certain aspects of the appeals process for appellants and adjudicators alike.  The changes will be effective 60 days after publication in the Federal Register, and we look forward to seeing their positive impact on the Medicare appeals process.

The Honorable Nancy Griswold
Chief Administrative Law Judge,
Office of Medicare Hearings and Appeals

The Honorable Constance B. Tobias
Chair, Departmental Appeals Board