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Medicare appeals process too slow, GAO report finds

Government officials agree that inefficiencies need to be addressed.

By Tanya Albert, amednews staff. Nov. 17, 2003.

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Physicians' and patients' appeals of Medicare claims denials are not being heard as quickly as the government requires, and hang-ups in administrative processing seem to be to blame, says a new General Accounting Office report.

Insurance carriers that contract with Medicare are responsible for the first two levels of appeals. They completed only 43% of first-level appeals within the 30 days required under the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000, known as BIPA, the report says.

The highest level of appeals -- handled by Social Security Administration's Office of Hearings and Appeals and Health and Human Services' Medicare Appeals Council -- had average processing times more than four times longer than BIPA mandates, the report found.

The act required the shorter appeals time frame to go into effect Oct. 1, 2002, but the appeals bodies haven't implemented many changes yet, the GAO reported. "The lack of a single entity to set priorities and address operational problems -- such as incompatible data and administrative systems -- at all four levels of the process has precluded successful management of the appeals system as a whole," the GAO said.

In the Office of Hearings and Appeals, an appeal takes an average of 14 months to be resolved, with 10 months spent in "administrative processing." In the last four months, the appeal is under legal analysis and adjudication. In HHS' Medicare Appeals Council, appeals take an average of 21 months to be resolved, with 17 of them spent in administrative processing. The last four months, again, are spent in legal analysis and adjudication.