The Centers for Medicare and Medicaid Services (CMS) recently issued a Final Rule to streamline and address the substantial backlog of Medicare administrative appeals at the Administrative Law Judge (ALJ) and Departmental Appeals Board (DAB)/Medicare Appeals Council levels.
Among other changes to the appeals process, the Final Rule:
- Permits the designation of Medicare Appeals Council decisions as precedential, in order to provide clarity
- Gives attorney adjudicators certain authority that had been previously reserved to the ALJs, including the authority to decide appeals that can be determined without a hearing, to review dismissals by the Qualified Independent Contractors (QIC) and Independent Review Entities (IRE), to issue remands to CMS contractors, and to dismiss requests for hearing when a request is withdrawn by an appellant
- Limits the number of CMS or CMS contractors that can be a participant or party at the hearings
- Creates efficiencies by, among other things, allowing ALJs to vacate their own dismissals as opposed to requiring the appellants to appeal a dismissal to the Medicare Appeals Council, using telephone hearings, and requiring appellants to provide more information on what is being appealed
- Establishes an adjudication time frame for cases remanded from the Medicare Appeals Council
- Revises remand rules to keep cases moving forward and simplifies the escalation process
- Provides increased specificity on what would be considered good cause for new evidence to be introduced at the ALJ level