Medicare beneficiaries
continue to be erroneously denied the coverage to which they are entitled.
Despite court rulings and regulations to the contrary we are finding that many
nursing facilities continue to deny residents Medicare payment based on the
discredited “improvement standard.”
Observation Status
problems are also a growing concern for seniors who receive hospital treatment. If you
need nursing home care after your hospitalization, it is very important that your
hospitalization was an “inpatient admission.” (Medicare will only cover nursing
home care after a 3-day inpatient hospital stay.) See Beware
of Hospital "Observation Status."
Medicare beneficiaries who are wrongly denied coverage have a right to appeal. But, until recently, pending appeals could be sunk for years in a Medicare bureaucratic bog.
But there is some good
news. A recent article written by Susan Jaffe and
originally published by Kaiser Health News notes that while the number of
appeals has been growing, wait times have been cut dramatically for Medicare
beneficiaries.
Here is that article (reproduced with permission).
Seniors’ Wait For A Medicare Appeal Is Cut In Half
The federal office responsible for appeals for Medicare
coverage has cut in half the waiting time for beneficiaries who are requesting
a hearing before a judge.
The progress follows an announcement last January that
officials were going to work through a crushing backlog by moving beneficiaries
to the front of the line and suspending hearings on cases from hospitals,
doctors and other providers for at least two years.
The Office
of Medicare Hearings and Appeals (OMHA) has decided most of the 5,162
cases filed by beneficiaries in the fiscal year ending Sept. 30, plus 1,535
older cases, according to statistics provided to Kaiser Health News.
That’s a dramatic change from the year before, when a third
of beneficiary cases (1,493) were not decided and nearly half (1,705) of the
2012 cases also were unresolved.
Still, about 900,000 appeals are awaiting decisions, with
most filed by hospitals, nursing homes, medical device suppliers and other
health care providers, said Jason Green, OMHA’s program and policy director.
The wait times for health providers’ cases have doubled since last year, and
are nearly four times longer than the processing time for beneficiary appeals.
Hospitals file more appeals than any other provider. The
single largest reason is the increasing number of Medicare payment denials for
patients who have been admitted to the hospital but whom auditors later say
should have been kept instead for observation care, a status that reduces
payments.
Seniors also have long complained about observation care
because Medicare doesn’t cover follow-up nursing home care for observation
patients.
The rise in beneficiary appeal decisions is a direct result
of the “beneficiary-first” policy Chief Judge Nancy Griswold announced last January, said Green. The temporary measure
will remain in place as long as there is a backlog, he added.
Since then, beneficiaries have waited 113 days on average for
a hearing, compared to 235 days the year before, said Green. This includes
appeals from beneficiaries in traditional Medicare and private Medicare
Advantage insurance plans. It’s a big improvement but still not in compliance
with the federal requirement that an appeal be decided within 90 days after a
request for a hearing.
“We are striving toward that 90-day mark,” said Green, who
expects the beneficiary appeals backlog will continue to shrink next year.
Reaching the Office of Medicare Hearings and Appeals (OMHA)
is the third of four stages in the appeals process and the first opportunity for
Medicare beneficiaries or health care providers to present their case before a
judge. The odds of winning an appeal at the third stage are far better than at
the previous levels, which involve only a review of the case files, the Health
and Human Services inspector general has found.
But seniors seeking top priority treatment, must identify
themselves by addressing their appeal to an OMHA office in Cleveland and
writing “Attn: Beneficiary Mail Stop” on the envelope. Griswold announced the
new mail address last February, and it is part of the instructions
beneficiaries receive when their appeal is denied at the second level.
Beneficiary appeals filed before the new policy was
established may be languishing in the backlog pile until officials find them.
“Beneficiaries can help us to help them get to the front of
the line,” Griswold said at a meeting in October. She urged those beneficiaries
to write to her office using the special mailing address or to call her office
at 855-556-8475.
This article was written by was produced by Kaiser Health
News with support from The
SCAN Foundation and originally published on December 23, 2014. Kaiser Health News (KHN) is a
nonprofit national health policy news service.
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