Limit Denials through Proactive, Pre-Bill Auditing

The Department of Health and Human Services (“HHS”) issued a proposed rule, published in the Federal Register on July 5th, to change Medicare appeals procedures in an attempt to make the process more streamlined and efficient.  Currently, the HHS Office of Medicare Hearings and Appeals (“OMHA”) has a backlog of over 750,000 pending appeals resulting in hearing dates scheduled years out for healthcare providers.  OMHA’s current caseload capacity is 77,000 appeals per year.  The key proposed changes, outlined below, are estimated to reduce the number of appeals sent to the Administrative Law Judge (“ALJ”) by 23,650 each year.

Although progress, the math still results in multi-year waits for hearings and revenue tied up in the system. What can healthcare providers do to avoid the appeals mess?  Proactive pre-bill auditing.  Proactively reviewing claims before they are dropped results in quality claims going out the door – reduces denials, limits potential repayment, maximizes revenue and confirms compliance.  Healthcare organizations will spend less time working denials and defending appeals and will recognize revenue that would otherwise be tied up in the system.

To learn more about our pre-bill compliance audits contact Valerie Reich at

Key Provisions of Proposed Rule – Please Note Comments Due by August 29th!

  • Expands pool of non-ALJ adjudicators – OMHA would re-assign certain appeals (e.g., reviews of lower level contractor denials, remands for additional information) to non-ALJ adjudicators allowing ALJ judges to focus on cases going to a hearing. Any cases decided by the non-ALJ adjudicators would still be appealable to the ALJ.
  • Designate cases as precedential – Allow the HHS Department of Appeals Board to designate certain decisions from the Medicare Appeals Council as precedential. According to HHS, the benefit is two-fold: (1) consistent body of decisions for appellants to use in determining whether to appeal a case and (2) guidance for adjudicators on repetitive policy and legal questions. The decisions would be published in the Federal Register and publicly posted on the HHS website.



Recent Insights

Newsletter Sign-Up