Assignment of requests for administrative law judge hearings of denied Medicare claims suspended for at least two years

The Department of Health and Human Service’s Office of Medicare Hearing and Appeals (OMHA) announced in a memorandum that it has temporarily suspended assignment of new requests for an administrative law judge (ALJ) hearing for Medicare claims for at least two years. The suspension is being implemented to give the ALJs time to address the almost 357,000 pending appeals already assigned to the 65 ALJs.

The memorandum (which was addressed to OMHA appellants and sent to those with a large number of appeals pending before ALJs) stated that the suspension was effective as of July 15, 2013, and would affect most Medicare appeals at the ALJ appeal level. The suspension does not apply to beneficiary-initiated appeals, including Medicare Part D appeals, which, according to OMHA’s Chief ALJ, “are being assigned as they are docketed,” and “are prioritized by the assigned adjudicator.”

Moving forward, OMHA has said that it will take 18 - 24 weeks before new Medicare appeals are docketed, and 24 - 28 months for the appeal to be assigned to an ALJ (both timelines concurrently running from the filing date). In addition, appellants may have to wait up to another 6 months (after an appeal is assigned to an ALJ) for an appeal decision from an ALJ, “depending on the complexity of the case.”

We know that the news of this suspension of the part of the Medicare appeals process where providers are most likely to be successful will frustrate many of our clients who are either in the midst of the appeals process or considering whether to appeal denials in the future. The American Hospital Association has expressed its dissatisfaction with the suspension to CMS, arguing that the suspension violates the Medicare statute, which requires that ALJs issue a decision within 90 days of receiving a request for a hearing. We will be watching for updates on this and will report any developments in a future client bulletin.