The Centers for Medicare and Medicaid Services (CMS) has promulgated a proposed rule that makes numerous revisions to the appeals process for Medicare claims. If finalized, this proposed rule will mainly clarify the existing regulations regarding the Medicare appeals process. It will, however, also add two key concepts to help streamline the appeals process.
Major provisions of the proposed rule include:
- Using HHS’ final appeal decisions as precedent. The proposed rules enable the chair of the HHS Departmental Appeals Board to designate final decisions issued by the Medicare Appeals Council as precedent for future appeals. Notice will be provided in the Federal Register of any such final decisions designated as precedent. Those final decisions will also be published. Precedential final decisions must be followed by all lower tier decision makers, including CMS and its Medicare administrative contractors.
- Enabling attorney adjudicators to issue decisions in certain situations. The proposed rules introduce the use of “attorney adjudicators,” licensed attorneys employed by the Office of Medicare Hearings and Appeals who understand Medicare coverage and reimbursement laws and guidance. Attorney adjudicators will issue (i) decisions in cases where the regulations do not require a hearing overseen by an administrative law judge (ALJ), (ii) dismissals in cases in which “an appellant withdraws his or her request for an ALJ hearing,” and (iii) “remands for information that can only be provided by CMS or its contractors.” Attorney adjudicators will also be authorized to review Qualified Independent Contractor dismissals.
The proposed rule is scheduled to be published in the Federal Register on July 5, 2016. Comments to the rule are due by August 29, 2016.
