CHA News Article

Fairness Bill Introduced for RAC Program Appeals

Senate Finance Committee Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR) have introduced the Audit & Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) Act of 2015 (S. 2368). The legislation aims to improve the Medicare audit and appeals process, which has seen an increase in service provider appeals as a result of CMS’ audits on more than 1 billion claims in an effort to curb improper payments. According to the Department of Health and Human Services, the increase in appeals has caused a backlog of nearly 1 million claims for the Office of Medicare Hearing and Appeals.

To address the increase in appeals and backlogs, the legislation would:

  • Coordinate efforts between auditors and CMS to ensure all parties receive transparent data on audit practices, improved methodologies over time, and new incentives and disincentives to improve auditor accuracy;
  • Create an independent Ombudsman for Medicare Reviews and Appeals to assist in resolving complaints by appellants and those considering appeal, and to provide data on the number of determinations appealed, each appeal’s outcome, and aggregate appeal statistics for each contractor and provider type;
  • Establish a voluntary alternate dispute resolution process to allow for multiple pending claims with similar issues of law or fact to be settled as a unit, rather than as individual appeals;
  • Raise the amount in controversy for review by an administrative law judge to match the amount for review by district courts; and
  • Allow for sampling and extrapolation, with the appellant’s consent, to expedite the appeals process.

The bill was reported out of the committee earlier this year by a voice vote. CHA supports the measure.

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