Medicare claims appeals could slow down

The plan to move all of the process to HHS is too vague and raises serious concerns, the GAO says.

By David Glendinning, AMNews staff. Nov. 8, 2004.

Washington -- Doctors have complained for years that the process by which they can appeal Medicare claims decisions is poorly coordinated and slow. Now the Government Accountability Office is saying that a move aimed at fixing some of these problems actually could make things worse.

Last year's Medicare reform law mandates that the portion of the appeals process handled by the Social Security Administration be switched to the Dept. of Health and Human Services. But an October GAO report says plans for this transfer aren't adequate, and delays could be on the way.

That worries some experts in the medical community. "The system works less than optimally as it currently exists," said Paul Speidell, a government affairs representative for the Medical Group Management Assn. "Anything that slows things down further, including a tripped-up transition process, would be a negative."

In fiscal year 2003, Medicare denied about 136 million claims, which is about 13% of all claims submitted. More than 5 million of those decisions were appealed by beneficiaries, physicians or others.

When the federal government denies a physician's fee-for-service claim or accuses a doctor of receiving overpayments, he or she has the opportunity to take the matter through up to four levels of appeal, starting with the claims administration contractor and ending with the Medicare Appeals Council. The third level of adjudication is handled by the Social Security Administration's Office of Hearings and Appeals.