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Recent OMHA statistics show that beneficiaries[1] currently wait an average of 60 days[2] to obtain an Administrative Law Judge (ALJ) hearing and receive a decision. In contrast, non-beneficiaries (providers, suppliers, state Medicaid agencies, and others) wait an average of 1,303 days (over 3.5 years) to obtain an ALJ decision.[3] The much shorter average wait time … Read more

The Office of Medicare Hearings and Appeals (OMHA) is the agency that administers the Administrative Law Judge (ALJ) hearing program for Medicare Parts A, B, C and D appeals. OMHA has a Case Processing Manual that sets out day-to-day procedures for carrying out adjudicative functions, in accordance with applicable statutes, regulations, and OMHA directives. Importantly … Read more

On July 10, 2018, the President signed an Executive Order undermining the impartial hiring of Medicare Administrative law Judges (ALJs). The Order states that “conditions of good administration make necessary an exception to the competitive hiring rules and examinations for the position of ALJ.”  What this means is that ALJs will now be hired directly … Read more

Last week the Centers for Medicare & Medicaid Services released the Medicare premium, deductible and co-pay amounts for 2019.  Below are the 2019 cost-sharing amounts. Part A Premium (For those not automatically enrolled) 0-29 qualifying quarters of employment: $437.00 30-39 quarters: $240.00 Inpatient Hospital Deductible, Per Spell of Illness: $1,364.00 Co-pay, Days 1 – 60: … Read more

In January, Vermont Legal Aid and the Center for Medicare Advocacy settled a case on behalf of Medicare beneficiaries in the six New England states and New York who had had been denied coverage of home health services for not being “homebound.” The settlement in Ryan v. Price, 5:14-cv-269 (D. Vt.), calls for re-review of … Read more

On July 10, 2018, the President signed an Executive Order undermining the impartial hiring of Administrative law Judges (ALJs). The order states that “conditions of good administration make necessary an exception to the competitive hiring rules and examinations for the position of ALJ.”  What this really means is that ALJs will now be hired directly … Read more

The Bipartisan Budget Act of 2018 became law on February 9, 2018. The Act repealed the Medicare outpatient therapy caps, which functioned as a barrier to care for those receiving outpatient therapy services. Section 50202 of the Act, “Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy,” states that the repeal … Read more

Home health access problems have ebbed and flowed over the years, depending on the reigning payment mechanisms, systemic pressures, and misinformation about Medicare home health coverage.  Regrettably, as we’ve been reporting, it seems access issue are on the upswing.  Here is the first of several Practice Tips to help maximize Medicare-covered home care under the … Read more

Jimmo v. Sebelius, No. 11-cv-17 (D. VT), is a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who received care in skilled nursing facilities, home health care, and outpatient therapy and who were denied Medicare coverage on the basis that they were not improving or did not demonstrate a potential for improvement (known as … Read more

Since the Balanced Budget Act of 1997, outpatient therapy under Medicare Part B has been subject to dollar limits, or caps.[1]  During most of these 20 years, an “exceptions” process has allowed beneficiaries and providers to seek coverage above the caps.  The exceptions process expired December 31, 2017.  Although legislation to repeal the therapy caps … Read more

CMS recently finalized significant changes affecting Medicare appeals, particularly at the Administrative Law Judge (ALJ) level of review.  These changes apply to appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as … Read more

Pursuant to the settlement agreement in Exley v. Burwell, a class action brought by the Center to address delays in appeals at the Administrative Law Judge (ALJ ) level, the Office of Medicare Hearings and Appeals (OMHA) has established a new help line to troubleshoot beneficiary appeals.  In a September 1, 2016 announcement, OMHA introduced … Read more

On June 9, 2016, the Government Accountability Office (GAO) publicly released a report (dated May 2016) titled “Medicare Fee-For-Service: Opportunities Remain to Improve Appeals Process”.[1]   Among other things, the report analyzes the increased number of appeals in the system and the resulting backlog at the third level (Administrative Law Judge, or ALJ) and fourth level … Read more

Skilled nursing facilities (SNFs) often tell Medicare beneficiaries and their families that they intend to “discharge” a Medicare beneficiary because Medicare will not pay for the beneficiary’s stay under either Part A (traditional Medicare) or Part C (Medicare Advantage).  Such a statement unfortunately misleads many beneficiaries into incorrectly believing, not only that Medicare has decided … Read more

The Senate Finance Committee recently passed the Audit & Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) Act of 2015 (S. 2368).  The Act, intended to improve the Medicare audit and appeals process, would not, in fact, improve the appeals process for beneficiaries and leaves key beneficiary concerns unaddressed. The Bill does not address the … Read more

The Center for Medicare Advocacy is concerned that Medicare beneficiaries are being denied Medicare coverage for skilled services that are specifically listed as covered by Medicare in federal regulations. Medicare covers various skilled therapies (physical, speech–language pathology and occupational) and skilled nursing services, including observation and assessment, management and evaluation of a care plan, or … Read more

As we’ve previously reported, on April 28, 2015 the Senate Finance Committee held a hearing about the tremendous backlog of cases piled up at the Office of Medicare Hearings and Appeals (OMHA), the office that oversees Administrative Law Judges (ALJs), the third level of appeal in Medicare’s administrative appeals system.[1]  The Finance Committee hearing also … Read more

Government contractors administering Medicare benefits are routinely denying coverage to cancer patients for claims involving the surgical removal of decayed and infected teeth caused by an aggressive course of radiation treatment to the head and neck.[1] The decayed and infected teeth, when left untreated, place these cancer patients at increased risk for infection, thereby decreasing … Read more

This CMA Alert highlights a recent individual ALJ decision that sets out an important but often unrecognized beneficiary right to a written notice when he or she is about to use hospital “Lifetime Reserve Days.”  A hospital’s failure to provide appropriate notice in this context can lead to the waiver of a beneficiary’s liability for … Read more

June 10, 2015,  2:00pm – 3:00 PM EST Cost: $99.00 per site This webinar will examine proper dcumention of skilled care for the purposes of obtaining Medicare coverage.  The presentation will examine how to: Identify skilled care and document it  to avoid the need for appeals; Provide adequate documentation of the patient’s condition whether changing … Read more

The Medicare appeals system is not working. The success rate at the first two levels of appeal is staggeringly low for beneficiaries. It can take years to get an ALJ hearing decision – the third level of appeal, and the first real opportunity to get a coverage denial reversed. As we’ve previously reported, the Senate … Read more

On April 28, 2015, the Senate Finance Committee held a hearing entitled “Creating a More Efficient and Level Playing Field: Audit and Appeals Issues in Medicare.”[1] As noted by Chairman Hatch in his opening statement, Medicare’s hiring of contractors to conduct audits of claims submitted to Medicare “has led to a seemingly insurmountable increase in appeals, with … Read more

The Center for Medicare Advocacy’s 'Rubber Stamp' suit highlights the fact that 98% of Medicare appeals are denied at the first two levels of review June 5, 2014 – The Center for Medicare Advocacy filed a complaint in United States District Court in Connecticut yesterday against Kathleen Sebelius, Secretary of Health and Human Services, on behalf … Read more

If you are covered by Medicare and you have a long-term or chronic condition, you may be eligible to have Medicare re-review your claims that were denied in prior years.  Please read carefully. In addition to revising Medicare manual provisions to now allow Medicare coverage for skilled maintenance care, the Settlement Agreement in Jimmo v. … Read more

1. First Steps      Review the Center for Medicare Advocacy’s Self-help Packets and coverage guidelines regarding the particular level of care involved in the appeal at: https://www.medicareadvocacy.org.   Watch for, receive and review the Medicare Reconsideration decision.  If the decision denies Medicare coverage, you only have 60 days to appeal from the date of … Read more

Here’s the Issue  Expedited Medicare appeals and standard Medicare appeals are designed to address different things and there are situations where a Medicare beneficiary must pursue both types of appeals. Expedited Appeals – Address whether the provider’s termination of Medicare-covered services was proper. Standard Appeals – Address whether any subsequent services the beneficiary chose to … Read more

In November, the Office of Inspector General (OIG) issued a report entitled, "Improvements are Needed at the Administrative Law Judge Level of Medicare Appeals."  The report can be found at https://oig.hhs.gov/oei/reports/oei-02-10-00340.pdf.   In the report, the OIG interprets the overall percentage of fully favorable decisions awarded to appellants by Administrative Law Judges (ALJs) as evidence that … Read more

September 20, 2012 With the Balanced Budget Act of 1997 (BBA1997), Congress began an expansion of preventive benefits and services available through Medicare.[1]   The Medicare Modernization Act of 2003 (MMA) added additional preventive services.[2]  The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) made refinements to Medicare's preventive services.[3]  Finally, the Patient Protection … Read more

August 16, 2012 On June 1, 2012, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal No.R2480CP, which updates its instructions on the issuance of the Advance Beneficiary Notice (ABN), Form CMS-R-131.[1]  The changes are effective on September 4, 2012.[2]  The new transmittal is part of an ongoing effort by CMS to provide additional … Read more

On March 7, 2012, the Centers for Medicare & Medicaid Services (CMS) announced the redesign of the Medicare Summary Notice (MSN), the statement that informs Medicare beneficiaries about their claims for Medicare services and benefits.  The Medicare Summary Notice (MSN) generally sets out what Medicare has or hasn't covered, provides information about a beneficiary's payment … Read more

Medicare's limitation on liability (LOL) protections[1] apply when a provider believes that an otherwise covered Medicare item or service will be denied because the item or service is not reasonable and necessary[2] or is for custodial care.[3] In order to shift liability to the beneficiary, a provider is required to notify a beneficiary in advance … Read more

In a lengthy, detailed, and complex decision, a federal appellate court rejected the right of Part D beneficiaries to sue a plan for damages when the plan fails to enroll them in a timely manner.[1] The decision, which was issued on August 31, 2010, makes clear the Court's view that Congress did not intend beneficiaries … Read more

On December 9, 2009, the Centers for Medicare & Medicaid Services (CMS) issued final regulations for the Medicare Claims Appeals Process (Parts A & B combined) and for the application of certain appeals provisions to the Medicare prescription drug appeals process (Medicare Part D).  Both sets of rules were effective on January 8, 2010.  Appeal … Read more