Tag: Center for Medicare Advocacy

Complaints About Gaps in Medicare Advantage Networks Are Common. Federal Enforcement Is Rare.

By Susan Jaffe | KFF Health News | November 20. 2025

Along with the occasional aches and pains, growing older can bring surprise setbacks and serious diseases. Longtime relationships with doctors people trust often make even bad news more tolerable. Losing that support — especially during a health crisis — can be terrifying. That’s why little-known federal requirements are supposed to protect people with privately run Medicare Advantage coverage when contract disputes lead their health care providers and insurers to part ways.

But government documents obtained by KFF Health News show the agency overseeing Medicare Advantage does little to enforce long-standing rules intended to ensure about 35 million plan members can see doctors in the first place.

In response to a Freedom of Information Act request covering the past decade, the Centers for Medicare & Medicaid Services produced letters it sent to only five insurers from 2016 to 2022 after seven of their plans failed to meet provider network adequacy requirements — lapses that could, in some cases, harm patient care. [Continued on KFF Health News,  CBS News, US News & World Report and MedpageToday.]…

Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage

By Susan Jaffe, KFF Health News | March 29, 2024

Bart Klion (Hans Pennink for KFF Health News)

Bart Klion, 95, and his wife, Barbara, faced a tough choice in January: The upstate New York couple learned that this year they could keep either their private, Medicare Advantage insurance plan — or their doctors at Saratoga Hospital.

The Albany Medical Center system, which includes their hospital, is leaving the Klions’ Humana plan — or, depending on which side is talking, the other way around. The breakup threatened to cut the couple’s lifeline to cope with serious chronic health conditions.

Klion refused to pick the lesser of two bad options without a fight.

..With rare exceptions, Advantage members are locked into their plans for the rest of the year — while health providers may leave at any time. …But a few years ago, CMS created an escape hatch by expanding special enrollment periods, or SEPs, which allow for “exceptional circumstances.” Beneficiaries who qualify can request SEPs to change plans or return to original Medicare. [Continued on KFF Health News]…

Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients

By Susan Jaffe, KFF Health News | October 5, 2023

This article also ran in The Washington Post.

Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from h when she got surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to go home.

At the time, she could not walk more than a few feet, even with assistance — let alone manage the stairs to her front door, she said. She still needed help using a colostomy bag following major surgery.

“How could they make a decision like that without ever coming and seeing me?” said Sullivan, 76. “I still couldn’t walk without one physical therapist behind me and another next to me. Were they all coming home with me?”

UnitedHealthcare — the nation’s largest health insurance company, which provides Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. It does have naviHealth, a care management company bought by UHC’s sister company, Optum, in 2020. NaviHealth’s proprietary “nH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions, and other factors. Based on these comparisons, an algorithm anticipates what kind of care a specific patient will need and for how long. 

 

…Next year, the Centers for Medicare & Medicaid Services will begin restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.[Continued on Kaiser Health News and The Washington Post.]…

Nursing Home Surprise: Advantage Plans May Shorten Stays to Less Time Than Medicare Covers

“The health plan can determine how long someone is in a nursing home typically without laying eyes on the person.”

By Susan Jaffe  | Kaiser Health News | October 4, 2022 | This KHN story also ran on Fortune logo

Amy Loomis (left) and Paula Christopherson (photo by Charles Christopherson)

After 11 days in a St. Paul, Minnesota, skilled nursing facility recuperating from a fall, Paula Christopherson, 97, was told by her insurer that she should return home.

“This seems unethical,” said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended coverage for her mother’s nursing home care.  The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company’s decision, or go home.

But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasn’t well enough to leave.

Health care providers, nursing home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members’ coverage for nursing home and rehabilitation services before patients are healthy enough to go home.  [Full story in and Fortune, Kaiser Health News, The Philadelphia Inquirer, and Yahoo News]

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Seeking to Shift Costs to Medicare, More Employers Move Retirees to Advantage Plans

By Susan Jaffe  | Kaiser Health News | March 3, 2022 | This KHN story also ran in Fortune and The Dallas Morning News.

As a parting gesture to a pandemic-ravaged city, former New York Mayor Bill de Blasio hoped to provide the city with a gift that would keep on giving: new health insurance for 250,000 city retirees partly funded by the federal government. Although he promised better benefits and no change in health care providers, he said the city would save $600 million a year.

Over the past decade, an increasing number of employers have taken a similar deal, using the government’s Medicare Advantage program as an alternative to their existing retiree health plan and traditional Medicare coverage. …Scores of private and public employers offer Medicare Advantage plans to their retirees. Yet the details — and the costs to taxpayers — are largely hidden. Because the federal Centers for Medicare & Medicaid Services is not a party to the negotiations among insurers and employers, the agency said it does not have details about how many or which employers are using this strategy or the cost to the government for each retiree group. [Full story in Kaiser Health News, Fortune and The Dallas Morning News]  

 

 

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Medicare Patients Win the Right to Appeal Gap in Nursing Home Coverage

By Susan Jaffe | KAISER HEALTH NEWS | January 28, 2022

A three-judge federal appeals court panel in Connecticut has likely ended an 11-year fight against a frustrating and confusing rule that left hundreds of thousands of Medicare beneficiaries without coverage for nursing home care, and no way to challenge a denial.

The Jan. 25 ruling, which came in response to a 2011 class-action lawsuit eventually joined by 14 beneficiaries against the Department of Health and Human Services, will guarantee patients the right to appeal to Medicare for nursing home coverage if they were admitted to a hospital as an inpatient but were switched to observation care, an outpatient service. [Full story in Kaiser Health News and Modern Healthcare.] 

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Medicare’s Open Enrollment Is Open Season for Scammers

By Susan Jaffe  | Kaiser Health News | November 11, 2021 | This KHN story also ran in The Washington Post.

Finding the best private Medicare drug or medical insurance plan among dozens of choices is tough enough without throwing misleading sales tactics into the mix.  Yet federal officials say complaints are rising from seniors tricked into buying policies — without their consent or lured based on questionable information — that may not cover their drugs or include their doctors.

In response, the Centers for Medicare and Medicaid Services has threatened to penalize private insurance companies selling Medicare Advantage and drug plans if they or agents working on their behalf mislead consumers.  The agency has also revised rules making it easier for beneficiaries to escape plans they didn’t sign up for or enrolled in only to discover promised benefits didn’t exist or they couldn’t see their providers.

The problems are especially prevalent during Medicare’s open-enrollment period, which began Oct. 15 and runs through Dec. 7. A common trap begins with a phone call like the one Linda Heimer, an Iowa resident, received in October. [Full story in The Washington Post and Kaiser Health News.] 

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Under New Cost-Cutting Medicare Rule, Same Surgery, Same Place, Different Bill

By Susan Jaffe  | Kaiser Health News | March 21, 2021 | This KHN story also ran in The Washington Post

For years, Medicare officials considered some surgeries so risky for older adults that that the insurance program would cover the procedures only for patients admitted to the hospital. Under a new Medicare policy that took effect this year, these operations can be provided to patients who are not admitted. But patients still have to go to the hospital. The change saves Medicare money while patients can pay a larger share of the bill — for the same surgery at the same hospital.  [Full story in The Washington Post and Kaiser Health News.] 

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Nursing Homes Fined for COVID Infection Control Lapses

By Susan Jaffe  | Contributing Writer | MedPageToday  | November 25, 2020

During the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) has fined 218 nursing homes more than $17.6 million for the most serious infection control violations that put residents in “immediate jeopardy,” conditions CMS believes are likely to seriously injure or kill them.

More than 91,000 residents and staff of long-term care facilities have died after contracting COVID-19 — about 40% of the total deaths in the U.S., according to a Kaiser Family Foundation analysis. …Frustrated by repeated violations of infection control requirements during the pandemic, CMS raised the penalty amounts and announced a crackdown on egregious offenders in August. But the hard-line approach doesn’t seem to have produced the intended results. (Click here for a list of nursing homes that were fined.)  [Continued here.]

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Whether By Luck Or Safety Protocols, Some Nursing Homes Remain COVID-19 Free

BY SUSAN JAFFE  |  CONNECTICUT HEALTH INVESTIGATIVE TEAM   |  JUNE 15,2020           

The coronavirus has decimated many of the nation’s nursing homes, and elderly, chronically ill residents of these facilities account for 64% of the state’s 4,201 death toll. They are roughly 100 times more likely to die of the virus than other people in the state.

So, the fact that some 41 of Connecticut’s 214 nursing homes have managed to keep out the virus, according to an analysis by C-HIT, is both remarkable and mystifying. Did they just get lucky?

This article also ran on Connecticut Public Radio.

Administrators at several COVID-19-free facilities use the word “fortunate” to describe a situation they acknowledge could change at any time. [Continued here, with map and table of COVID-19 free nursing homes.]

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Class-Action Lawsuit Seeks To Let Medicare Patients Appeal Gap in Nursing Home Coverage

By Susan Jaffe  | Kaiser Health News | August 12, 2019 | This KHN story also ran on Salon and Next Avenue  

Medicare paid for Betty Gordon’s knee replacement surgery in March, but the 72-year-old former high school teacher needed a nursing home stay and care at home to recover.

Yet Medicare wouldn’t pay for that. So Gordon is stuck with a $7,000 bill she can’t afford — and, as if that were not bad enough, she can’t appeal.

The reasons Medicare won’t pay have frustrated the Rhode Island woman and many others trapped in the maze of regulations surrounding something called “observation care.”

Patients, like Gordon, receive observation care in the hospital when their doctors think they are too sick to go home but not sick enough to be admitted. They stay overnight or longer, usually in regular hospital rooms, getting some of the same services and treatment (often for the same problems) as an admitted patient….

(Photo courtesy of Betty Gordon)

But observation care is considered an outpatient service under Medicare rules, like a doctor’s appointment or a lab test. Observation patients may have to pay a larger share of the hospital bill than if they were officially admitted to the hospital.Medicare’s nursing home benefit is available only to those admitted to the hospital for three consecutive days. Gordon spent three days in the hospital after her surgery, but because she was getting observation care, that time didn’t count.

There’s another twist: Patients might want to file an appeal, as they can with many other Medicare decisions. But that is not allowed if the dispute involves observation care.

Monday, a trial begins in federal court in Hartford, Conn., where patients who were denied Medicare’s nursing home benefit are hoping to force the government to eliminate that exception. A victory would clear the way for appeals from hundreds of thousands of people.  [Continued at Kaiser Health News, Next Avenue or Salon]

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Home Health Care Providers Struggle With State Laws And Medicare Rules As Demand Rises

“We can send prescriptions to the pharmacy, including [for] narcotics,” says Marie Grosh, a geriatric advanced practice nurse practitioner and the owner of a medical house calls practice in a Cleveland suburb. “We can order lab work, x-rays, ultrasounds, EKGs [electrocardiagrams]; interpret them; and treat patients based on that. But we’re just not allowed to order home care—which is absurd.”

By SUSAN JAFFE  | Health Affairs | June 2019 | Volume 38, Number 8

When Christine Williams began working as a nurse practitioner some forty years ago in Detroit, Michigan, older adults who couldn’t manage on their own and had no family nearby and no doctor willing to make house calls had few options besides  winding up in a nursing home.

Not anymore.

Home check: Nurse practitioner Marie Grosh visits Leroy Zacharias at his home in a Cleveland suburb, He has Parkinson disease, and Grosh says he would be living in a nursing home if he couldn’t get medical care at home. (Photo by Lynn Ischay.)

“The move towards keeping seniors in their homes is a fast-galloping horse here,” says Williams, who settled in Cleveland, Ohio, more than a decade ago. “We don’t have space for them in long-term care [facilities], they don’t want to be in long-term care, and states don’t want to pay for long-term care. And everybody wants to live at home.”

But despite the growing desire for in-home medical care for older adults from nearly all quarters, seniors’ advocates and home health professionals claim that rules set by the Centers for Medicare and Medicaid Services (CMS)  along with  state regulations have created an obstacle course for the very providers best positioned—and sometimes the only option—to offer that care.  [Continued here] …

Trumpeted New Medicare Advantage Benefits Will Be Hard For Seniors To Find

By Susan Jaffe  | Kaiser Health News | November 9, 2018 | This KHN story also ran on 

For some older adults, private Medicare Advantage plans next year will offer a host of new benefits, such as transportation to medical appointments, home-delivered meals, wheelchair ramps, bathroom grab bars or air conditioners for asthma sufferers.

But the new benefits will not be widely available, and they won’t be easy to find.

Of the 3,700 plans across the country next year, only 273 in 21 states will offer at least one. About 7 percent of Advantage members — 1.5 million people — will have access, Medicare officials estimate.

That means even for the savviest shoppers it will be a challenge to figure out which plans offer the new benefits and who qualifies for them.

Medicare officials have touted the expansion as historic and an innovative way to keep seniors healthy and independent. Despite that enthusiasm, a full listing of the new services is not available on the web-based “Medicare Plan Finder,” the government tool used by beneficiaries, counselors and insurance agents to sort through dozens of plan options. [Continued at Kaiser Health News, NPR and CNN]…

Lifting Therapy Caps Is A Load Off Medicare Patients’ Shoulders

Last month’s budget deal means Medicare beneficiaries are eligible for physical and occupational therapy indefinitely. Plus, prescription drug costs will fall for more seniors.

By Susan Jaffe  | Kaiser Health News | March 14, 2018 | This KHN story also ran on 

Physical therapy helps Leon Beers, 73, get out of bed in the morning and

Leon Beers gets help from caregiver Timothy Wehe. (Bert Johnson for KHN)

maneuver around his home using his walker. Other treatment strengthens his throat muscles so that he can communicate and swallow food, said his sister Karen Morse. But in mid-January, his home health care agency told Morse it could no longer provide these services because he had used all his therapy benefits allowed under Medicare for the year.

… Under a recent change in federal law, people who qualify for Medicare’s [physical, occupational and speech] therapy services will no longer lose them solely because they used too much. 

“It is a great idea,” said Beers. “It will help me get back to walking.” [Continued at Kaiser Health News,  NPR  and The Washington Post]

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Home Care Agencies Often Wrongly Deny Medicare Help To The Chronically Ill

By Susan Jaffe  | Kaiser Health News | January 18, 2018 | This KHN story also ran on     

Colin Campbell    (Heidi de Marco/KHN)

Colin Campbell needs help dressing, bathing and moving between his bed and his wheelchair. He has a feeding tube because his partially paralyzed tongue makes swallowing “almost impossible,”he said.

Campbell, 58, spends $4,000 a month on home health care services so he can continue to live in his home just outside Los Angeles. Eight years ago, he was diagnosed with amyotrophic lateral sclerosis, or “Lou Gehrig’s disease,” which relentlessly attacks the nerve cells in his brain and spinal cord and has no cure.

The former computer systems manager has Medicare coverage because of his disability, but no fewer than 14 home health care providers have told him he can’t use it to pay for their services. That’s an incorrect but common belief….  [Continued at Kaiser Health News and NPR]…

Judge Accepts Medicare’s Plan To Remedy Misunderstanding On Therapy Coverage

By Susan Jaffe  | Kaiser Health News | February 3, 2017 | This KHN story also ran on     

A federal judge has accepted Medicare’s plans to try once more to correct a commonly held misconception that beneficiaries’ are eligible for coverage for physical and occupational therapy and other skilled care only if their health is improving.

“Confusion over the Improvement Standard persists,” wrote U.S. District Court Chief Judge Christina Reiss in Vermont in a decision released by the court Thursday. Advocates for seniors say coverage is often mistakenly denied simply because the beneficiary reaches “a plateau” and is no longer making progress.[Continued at Kaiser Health News and NPR]…

Medicare’s Coverage Of Therapy Services Again Is In Center Of Court Dispute

By Susan Jaffe  | Kaiser Health News | January 30, 2017 | This KHN story also ran on     

Four years after Medicare officials agreed in a landmark court settlement that seniors cannot be denied coverage for physical the
rapy and other skilled care simply because their condition is not improving, patients are still being turned away.

So federal officials and Medicare advocates have renewed their court battle, acknowledging that they cannot agree on a way to fix the problem. Earlier this month, each submitted ideas to the judge, who will decide — possibly within the next few months — what measures should be taken.

Several organizations report that the government’s initial education campaign following the settlement has failed. Many seniors have only been able to get coverage once their condition worsened. But once it improved, treatment would stop — until they got worse and were eligible again for coverage.

Every year thousands of Medicare patients receive physical therapy and other treatment to recover from a fall or medical procedure, as well as to help cope with disabilities or chronic conditions including multiple sclerosis, Alzheimer’s or Parkinson’s diseases, stroke, and spinal cord or brain injuries. [Continued at Kaiser Health News and NPR] …

New Nursing Home Rules Offer Residents More Control Of Their Care

By Susan Jaffe  | Kaiser Health News | January 4, 2017 |  This KHN story also ran in 

About 1.4 million people living in nursing homes across the country can now be more involved in their care under the most wide-ranging revision of federal rules for such facilities in 25 years.

The changes reflect a shift toward more “person-centered care,” including requirements for speedy development of care plans, more flexibility and variety in meals and snacks, greater review of a resident’s drug regimen, better security, improved grievance procedures, and scrutiny of involuntary discharges.

“With proper implementation and enforcement, this could really transform a resident’s experience of a nursing home,” said Robyn Grant, director of public policy and advocacy for the Consumer Voice, a national group that advocates for residents’ rights. The federal Medicare and Medicaid programs pay for most of the nation’s nursing home care — roughly $75 billion in 2014 — and in return, facilities must comply with government rules. [Continued in  Kaiser Health News and The Washington Post]

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Seeking Dental Care For Older Americans

Since Medicare doesn’t cover most dental care, seniors often go without treatment.

By SUSAN JAFFE  | Health Affairs | December 2016 | Volume 35, Number 12

The last time Evelyn Sell went to the dentist was nearly three years ago, when he told her his staff would no longer be able to lift her out of her wheelchair and into the dentist’s chair. “That really threw me for a loop,” said Sell, 87, a retired preschool teacher who lives in Kingsley Manor, a retirement community in Los Angeles. “I didn’t know what I was going to do about dental care.”

Care at home: During a recent visit to Kingsley Manor, a Los Angeles, California, senior living community, dental hygienist Maria Ladd uses an intraoral camera to take photos of resident Ruth Wilson’s teeth. (Photo: Susanna Castillo)

…Then earlier this year, she found the solution. A flyer in her mail informed her that the management of her assisted living facility had partnered with the Virtual Dental Home project run by Pacific Center for Special Care at the University of the Pacific in San Francisco. Sell could have a dental hygienist come to her home. She was one of the first residents to sign up.

The project is one of several innovative demonstrations that providers and researchers are developing to serve vulnerable uninsured or underinsured patients. Despite their promise, however, these efforts meet only a fraction of the need. A comprehensive solution would likely require federal legislation, but bills to broadly expand Medicare’s dental coverage have languished in Congress. So some advocates for older adults are working on a third front, seeking changes to Medicare coverage policy based on the idea that dental care can be an integral part of the medically necessary care Medicare covers. [Continued here] …

Medicare Bars New ‘Seamless Conversion’ Efforts For Some Seniors

By Susan Jaffe  | Kaiser Health News | October 28, 2016 |  This KHN story also ran in 

The federal government is temporarily blocking more health insurance companies from automatically moving customers who become eligible for Medicare into Medicare Advantage plans while officials review the controversial practice.

They also will issue rules soon for plans that already have permission to make these switches, known as “seamless conversion,” according to a memo from Michael Crochunis, acting director of the Medicare Enrollment and Appeals Group at the Centers for Medicare & Medicaid Services.

Under current rules, an insurer can transfer customers who have purchased policies through an Affordable Care Act insurance exchange or other commercial plans when they become eligible for Medicare, typically at age 65. An insurer must give an individual 60 days’ advance written notice of the switch; if a person doesn’t opt out, that enrollment takes effect automatically.

… The decision to prohibit additional insurers from pursuing Medicare Advantage conversions comes after Kaiser Health News and The Washington Post identified problems with the practice in July. Some seniors did not know they had different coverage until receiving out-of-network providers’ bills for thousands of dollars. Others got the news when they received a Medicare Advantage membership card they hadn’t requested — with the name of a new primary care doctor they didn’t know. [Continued in Kaiser Health News and The Washington Post]…

Some Seniors Surprised To Be Automatically Enrolled In Medicare Advantage Plans

By Susan Jaffe  | Kaiser Health News | July 27, 2016 |  This KHN story also ran in 

Only days after Judy Hanttula came home from the hospital after surgery last November, her doctor’s office called with bad news: Records showed that instead of traditional Medicare, she had a private Medicare Advantage plan, and her doctor and hospital were not in its network.

Neither the plan nor Medicare now would cover her medical costs. She owed $16,622.

“I was panicking,” said Hanttula, who lived in Carlsbad, N.M., at the time. After more than five hours making phone calls, she learned that because she’d had individual coverage through Blue Cross Blue Shield when she became eligible for Medicare, the company automatically signed her up for its own Medicare Advantage plan after notifying her in a letter. Hanttula said she ignored all mail from insurers because she had chosen traditional Medicare.

“I felt like I had insured myself properly with Medicare,” she said. “So I quit paying attention to the mail.”

With Medicare’s specific approval, a health insurance company can enroll a member of its marketplace or other commercial plan into its Medicare Advantage coverage when that individual becomes eligible for Medicare. Called “seamless conversion,” the process requires the insurer to send a letter explaining the new coverage, which takes effect unless the member opts out within 60 days. [Continued in The Washington Post and Kaiser Health News]…

Democrats back Clinton, progressive platform at DNC in Philadelphia

Susan Jaffe | Washington Correspondent for The Lancet | 29 July 2016

Vermont Sen. Bernie Sanders stressed the need for unity when he addressed the convention on its first day, citing the Democratic party platform as evidence of the gains his supporters have achieved. “It is no secret that Hillary Clinton and I disagree on a number of issues … that’s what democracy is about,” Sanders told the convention. “But I am happy to tell you that at the Democratic Platform Committee, there was a significant coming together between the two campaigns and we produced, by far, the most progressive platform in the history of the Democratic Party.” [continued here] [listen to podcast here]…

HHS Proposes To Streamline Medicare Appeals Process

By Susan Jaffe  | Kaiser Health News | June 29, 2016 | This KHN story also ran on     nprlogo_138x46

The Department of Health and Human Services Tuesday proposed key changes in the Medicare appeals process to help reduce the backlog of more than 700,000 cases involving denied claims.

The measures “will help us get a leg up on this problem,” said Nancy Griswold, chief law judge of the Office of Medicare Hearing and Appeals.

If there weren’t a single additional appeal filed and no changes in the system, it would take 11 years to eliminate the backlog, Griswold said in an interview. [Continued on NPR or KHN]  …

Senate Panel Kills Medicare Program That Offers Help On Enrollment, Billing Issues

By Susan Jaffe  | Kaiser Health News | June 17, 2016 | This KHN story also ran on     nprlogo_138x46

A program that has helped seniors understand the many intricacies of Medicare as well as save them millions of dollars would be eliminated by a budget bill overwhelmingly approved last week by the powerful Senate Appropriations Committee.

The State Health Insurance Assistance Program, or “SHIP,” is among more than a dozen programs left out of the bill by the committee. Cutting these “unnecessary federal programs” helped provide needed funding for other efforts, Sen. Roy Blunt, R-Mo., chairman of the appropriations committee’s health and labor subcommittee, said in a statement last week.

Ending SHIP saves $52 million, which will help pay for a $2 billion increase for the National Institutes of Health, restore year-round Pell Grants, and increase resources to prevent and treat opioid abuse, among other things.

SHIP counselors are in every state, the District of Columbia and the U.S. territories offering free advice on how to choose from an array of drug and health insurance plans, challenge coverage denials, and receive financial subsidies for premiums, co-payments and deductibles. …Ohio’s SHIP program saved seniors $20.8 million in 2015 and was ranked first in the nation by the Department of Health and Human Services, the state’s lieutenant governor announced in February. [Continued on Kaiser Health News or NPR]

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Medicare’s Efforts To Curb Backlog Of Appeals Not Sufficient, GAO Reports

By Susan Jaffe  | Kaiser Health News |  June 10, 2016

 Despite interventions by Medicare officials, the number of appeals from health care providers and patients Growing Wait Time1challenging denied claims continues to spiral, increasing the backlog of cases and delaying many decisions well beyond the timeframes set by law, according to a government study released Thursday.

The report from the Government Accountability Office, said the backlog “shows no signs of abating.” It called for the Department of Health and Human Services to improve its oversight of the process and to streamline appeals so that prior decisions are taken into account and repetitive claims are handled more efficiently.

HHS officials have acknowledged the problem. Although a judge is required to issue a decision within 90 days, the average time from hearing request to decision is slightly more than two years, Nancy Griswold, the chief administrative law judge of the Office of Medicare Hearings and Appeals, said in an interview.

Requests for hearings increased “so dramatically and so quickly over the past four or five years — during a period of time when our adjudication capacity was not able to keep up for funding reasons — we were drowning” in appeals, she said. “It is not quite as bad right now, but we are unable to keep up with [those] that are coming in the door.”  [Continued]…