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National Medicare Advocates Alliance
Issue brief #18



    Based upon the Center’s extensive experience with the Medicare administrative appeals process, we are continuing to find that: 1) the success rate for beneficiaries at the initial levels of appeal is generally very low; and 2) once appeals get to the Administrative Law Judge (ALJ) stage, where chances of success improve dramatically, and at the subsequent stage of appeal, the Medicare Appeals Council (MAC), the issuance of decisions often far exceeds built-in timeframes (e.g., 90 days).

    We would like to know what others are experiencing – are you seeing unreasonable delays and low rates of success in the early stages?

    Additional background information:

    • Here is a link to information on the Center’s website about Medicare appeals, including Self-Help Packets for Skilled Nursing Facility, Home Health, and Outpatient Physical Therapy Denials:
    • The following is an excerpt of comments submitted by the Center for Medicare Advocacy to the Senate Finance Committee re: Medicare Fraud, focusing on the performance of Medicare Administrative Contractors and the low rates of success at the initial stages of appeal (June 2012):

Since 1986 the Center for Medicare Advocacy has assisted thousands of Medicare beneficiaries and their families to challenge unfair Medicare denials. Thus, the Center has unique and extensive experience with the Medicare administrative appeals process and decision-making. Regrettably, the quality of decisions by the private entities that issue the first two levels of appeal determinations has deteriorated so significantly that these steps are all but worthless to beneficiaries. Known as Medicare Administrative Contractors (MACs), these contracted decision-makers rarely grant coverage, accurately recount the facts of the individual case, or explain the reason for their denial.

Suggesting the MACs have a rubber stamp denial rate is hardly an exaggeration. In fact, of the 2,045 redetermination decisions received by the Center last quarter for skilled nursing facility and home health care, the Medicare Contractors granted coverage in only 3 cases. Yet, our general experience is that at least half of cases that are brought to the Administrative Law Judge (ALJ) level in fact receive coverage. This cannot possibly reflect a full and fair review of the facts of each case in light of Medicare coverage criteria. Adding insult to injury, in some instances, the MACs actually take back coverage that was previously granted. This occurs, for example, in situations where some, but not all, of the services during a home health episode were previously covered by Medicare. In such cases, the MAC may not only deny an appeal for the rest of the episode, but also retract coverage that was previously provided.

  • On April 6, 2012, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 17, which revises and creates new procedures for the review of quality of care concerns by Quality Improvement Organizations (QIOs). Effective May 7, 2012, the new procedures apply to QIO review of the quality of services "among different cases and settings (including post-acute-care settings, ambulatory settings, and health maintenance organizations)."  In addition, CMS recently issued a Notice of Proposed Rule Making (NPRM) which discusses and, for the most part, incorporates the content of Transmittal 17.

    The procedures are complicated, but it is hoped that they will become more streamlined going forward.  However, despite the complexity of the procedures, we believe it is good that a structure for providing beneficiaries with more information about the resolution of quality of care complaints has been created.


  • Things to look out for during the Lame Duck session of Congress after the election:
    • Extenders package – physician payment (sustainable growth rate, or SGR – 27% cut scheduled for January 2013), extension of Qualified Individual (QI) program, and extension of therapy cap exceptions.
    • Sequester – automatic $1.2 trillion in spending cuts over 10 years due to failure of 2011 SuperCommittee under Budget Control Act of 2011; $110 billion in 2013 sequester cuts do not include Social Security, Medicaid, SSI and certain other programs, but include a 2% provider cut in Medicare (totaling approximately $11 billion).

See website of the Leadership Council on Aging (LCAO) in coming weeks for principles, fact sheets and issue briefs on various topics, including sequester, premium support, Medicaid block grants, dual eligible integration demonstrations and Medicare beneficiary demographics and out of pocket expenses:


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