U.S. District Federal Judge James Boasberg in Washington D.C. has ruled that HHS must eliminate the backlog of Medicare claims appeals by the end of fiscal year 2022. The total queued claim count is well over 400,000. In his ruling, Judge Boasberg also required HHS to provide status updates and meet certain milestones to get the backlog down during the next few years. Word on the street among providers is that the experience overall with Medicare Audit Contractors (MACs) has not been great, and the MAC interpretations of CMS guidelines have often been inaccurate and inconsistent. Many providers are claiming that they are ultimately successful in their appeals of initial decisions over 90% of the time. Another major concern among providers is that education provided by MAC reviewers has been incorrect.
Recommendations have been made for CMS to take a long hard look at its MACs performing these reviews, including analyzing the overall knowledge and competency of the MAC Clinical Reviewers performing the first level reviews. At the moment, these issues are causing significant cash flow problems for some providers and are adding additional cost to our already expensive healthcare system.
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