Health Information Management

News: Pilot programs aim to reduce appeals’ backlog

CDI Strategies, July 17, 2014

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Statistical sampling or alternative dispute resolution: These possible two solutions to the backlog of Medicare claim denial appeals are getting a trial run in the near future, according to a Report for Medicare Compliance article.

The AHA and three hospitals have an ongoing lawsuit regarding the appeals process, and Friday, July 11, they asked a federal court to grant an immediate favorable ruling to compel the Department of Health and Human Services to meet statutory deadlines for timely administrative review of Medicare claims denials.

It may take nearly 400 days to set a hearing and resolve an appeal, according to Nancy Griswold, chief ALJ from the Department of Health and Human Services’ Office of Medicare Hearing and Appeals (OMHA), the AHA’s News Nowreported. According to the AHA’s most recent RACTrac report, hospitals are appealing nearly 50% of their claims denials.

The statistical sampling option essentially allows facilitates with large numbers of claims to resolve them based on a statistically valid sample and extrapolation. The other option essentially sends the appeal to OMHA attorneys who mediate the case. (For more information, visit

Despite an abundance of audits, the Medicare fee-for-service improper payment rate rose in fiscal year 2013 to 10.1%, up from 8.5% in 2012, according to a July 9 report from the Senate Committee on Aging, AIS Health reported.

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