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Push on to clear Medicare appeals backlog

Medicare beneficiaries who have been waiting months and even years for a hearing on their appeals for coverage may soon get a break as their cases take top priority in an effort to remedy a massive backlog.

Nancy Griswold, the chief judge of the Office of Medicare Hearings and Appeals, announced in a memo sent last month to more than 900 appellants and health-care associations that her office has a backlog of nearly 357,000 claims.

In response, she said, the agency has suspended action on new requests for hearings filed by hospitals, doctors, nursing homes and other health-care providers, which make up nearly 90 percent of the cases. She said that she expected the suspension would last about two years.

But beneficiaries’ appeals will continue to be processed, and officials are seeking to “ensure that the relatively small numbers of beneficiary-initiated appeals are being immediately addressed by prioritizing their cases,” the Department of Health and Human Services said in a statement.

“Because they are among our nation’s most vulnerable populations, OMHA is committed to being as responsive as possible to the Medicare beneficiary community, regardless of the challenges presented by the significant increase in the number of requests being filed,” Griswold wrote. From 2010 through 2013, the cases grew by 184 percent “while the resources to adjudicate the appeals remained relatively constant,” Griswold said.

The office received 1,250 appeals weekly in January 2012, but that number had ballooned to more than 15,000 a week by last November, and the average waiting time is now 16 months. Her office has 65 administrative law judges.

“We have elderly or disabled Medicare clients waiting as long as two years for a hearing and nine months for a decision,” said Judith Stein, executive director of the Center for Medicare Advocacy. They are typically appealing the denial of coverage for home care, nursing-home care, ambulance trips and other services.

Among them is a Connecticut man who requested a hearing a year ago to appeal the denial of nursing-home coverage. He has since died, but his family is pursuing the case, which is set for a hearing in October.

Hospitals report that the waiting time for decisions on their appeals exceeds the legal limit of 90 days, said Melissa Jackson of the American Hospital Association. Adding two years to the process “is a violation of the statute,” she said.

Jackson blamed the delays on increased scrutiny of hospital charges by recovery-audit contractors whose payments are based on the number of questionable claims they uncover. Hospitals are then forced to appeal these denials, she said.