Providers File The Bulk Of Medicare Appeals

Kaiser Health News: By Susan Jaffe, NOVEMBER 15TH, 2012, 7:30 AM

Health care providers who appealed to Medicare judges won more often than patients did,according to a report by the inspector general at the U. S. Department of Health and Human Services.

Hospitals, physicians, medical equipment suppliers and other providers also filed 85 percent of the cases decided by the administrative law judges in fiscal year 2010.   Some providers get plenty of practice, with 96 “frequent filers” responsible for one-third of the 40,682 appeals submitted to the judges, the IG found.

The report noted that some providers routinely appeal every denial “because the cost is nominal and a favorable decision is likely.”

Medicare beneficiaries and providers can challenge the denial of a claim in several appeals stages, but the first two are decided by contractors working for Medicare who base their opinions on case files.  In the third step, which is the focus of the report, appellants have a hearing before a judge, testimony can be provided, witnesses can be cross-examined, and new evidence can be introduced.  The judges are lawyers in the Office of Medicare Hearings and Appeals, an independent agency within HHS. Read more