CMS Ditches Signatures to Improve Medicare Appeals Process

May 13, 2019 - CMS recently finalized a rule that aims to streamline the Medicare appeals process and reduce provider burden by eliminating signature requirements for appeal requests.

The rule published on May 7 states that appellants in Medicare Parts A and B claim and Part D coverage determination appeals will be able to submit appeal requests similar to the way they would at the Office of Medicare Hearings and Appeals (OMHA) – without a signature.

CMS does not require a provider or beneficiary signature when an appellant requests OMHA review of Parts A and B claim determinations, or when the appellant requests a redetermination, reconsideration, or OMHA review of Part D determinations.  

Additionally, there is no signature requirement at the Part C level.

Eliminating the signature requirement for Parts A and B claim and Part D coverage determination appeals should simplify the Medicare appeals process for providers and beneficiaries, CMS hopes.

“In order to promote consistency between appeal levels, ensure transparency in developing our appeal request requirements, help ensure that we do not impose nonessential requirements on appellants, reduce the burden on appellants, and improve the appeals process based on our experience, we proposed that appellants in Medicare Parts A and B claim and Part D coverage determination appeals be allowed to submit appeal requests without a signature,” the federal agency says in the final rule.

In addition to signature requirements, CMS intends to simplify the Medicare appeals process by:

• Switching the timeframe for vacating dismissals from months to calendar days, so the regulation states 180 calendar days rather than six months
• Revising the timeframe for referring a case to the Medicare Appeals Council to 60 calendar days after CMS or contractors receive a written decision or dismissal
• Updating the process so when an appeal involves an overpayment, the amount in controversy is the amount listed in the demand letter or the amount of the revised overpayment if the amount originally demanded changes because of determinations or appeals

The changes to the Medicare appeals process may not be revolutionary, but the final rule demonstrates CMS’ commitment to improving the complex, burdensome process for providers.

The Medicare appeals process had a backlog of 426,594 appeals in the fiscal year (FY) 2018, recent court documents show. And the average processing time for claims at the OMHA level is currently 1,321.1 days, which is up from 1,193.9 in FY 2018, HHS reports.

Greater propensity of providers to appeal claims and increased program integrity efforts resulted in the Medicare appeals backlog, HHS explains.

Over the past decade, HHS has seen an uptick in Medicare appeals. The number of appeals at the OMHA level of the appeals process increased 936 percent from 2010 to 2014, with the number of appeals at the level related to hospitals and other inpatient stays specifically growing over 2,000 percent during the period, the Government Accountability Office (GAO) finds.

The backlog has grown so much that a federal judge recently ordered HHS to eliminate all the appeals stuck in the process by the end of FY 2022.

HHS and CMS are taking steps to decrease the backlog and streamline the Medicare appeals process. For example, HHS recently asked Congress to increase funding for the Medicare appeals process and policymakers approved a 70 percent increase in funding to allow the HHS to hire more administrative law judges.

HHS has also announced several settlement opportunities for providers. Most recently, CMS offered to pay providers with a low volume of appeals 62 percent of the billed amount of the claims. In exchange, providers had to withdraw all eligible claims from the appeals process.

The efforts to streamline the process and address the backlog are working to an extent. The backlog of Medicare appeals at the OMHA level fell from 886,000 appeals pending in 2015 to 417,198 appeals pending by the end of 2018, according to an HHS report acquired by the American Hospital Association (AHA) in January. Recovery audit contractor appeals also declined from almost 50,000 to 774 at the same time.

Addressing the backlog of pending appeals is a top HHS priority. But the federal department and its agencies are also working to improve the Medicare appeals process to prevent another backlog. Updating process rules are small but significant steps to improving the overall process.