• Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer
  • Donate Now
  • Sign Up

Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

  • Eligibility/Enrollment
  • Coverage/Appeals
    • Medicare Costs (2021)
    • Self Help Materials – Toolkits & More
  • Topics
    • Basic Introduction to Medicare
    • COVID-19 and Medicare
    • Medicare Costs (2021)
    • Home Health Care
    • Improvement Standard and Jimmo News
    • Nursing Home / Skilled Nursing Facility Care
    • Outpatient Observation Status
    • Part B
    • Part D / Prescription Drug Benefits
    • Medicare for People Under 65
    • Medicare “Reform”
    • All Other Topics
    • Resources
      • Infographics
  • Publications
    • CMA Alerts
    • Fact Sheets & Issue Briefs
    • Infographics
    • The Medicare Handbook
    • SNF Enforcement Newsletter
    • Elder Justice Newsletter
    • Medicare Facts & Fiction
    • Articles by Topic
  • Litigation
    • Litigation News
    • Cases
    • Litigation Archive
    • Amicus Curiae Activities
  • Newsroom
    • Press Releases
    • Editorials & Letters to the Editor
    • CMA Comments, Responses, and Letters
    • Medicare Facts & Fiction
    • CMA in the News
  • About Us
    • Mission Statement
    • CMA FAQs
    • Personnel & Boards
    • The Center for Medicare Advocacy Founder’s Circle
    • Connecticut Dually Eligible Appeals Project
    • Ossen Medicare Outreach, Education and Advocacy Project
    • National Medicare Advocates Alliance
    • National Voices of Medicare Summit
    • CMA Webinars
    • Products & Services
    • Testimonials
    • Career, Fellowship & Internship Opportunities
    • Contact Us
  • Support Our Work
    • Donate Now
    • Join the Center for Medicare Advocacy Founder’s Circle
    • Take Action
    • Share Your Health Care Story
    • Tell Congress to Protect Our Care
    • Listen to Medicare & Health Care Stories
    • Sign Up

October 2012 – Updates on Medicare Appeals and Complaints

October 15, 2012

Print Friendly, PDF & Email

National Medicare Advocates Alliance
Issue brief #18

1.  PRESENTATIONS

  • ADMINISTRATIVE REVIEW PROCESS:  LITTLE SUCCESS, LONG DELAYS

    Based upon the Center’s extensive experience with the Medicare administrative appeals process, we are continuing to find that: 1) the success rate for beneficiaries at the initial levels of appeal is generally very low; and 2) once appeals get to the Administrative Law Judge (ALJ) stage, where chances of success improve dramatically, and at the subsequent stage of appeal, the Medicare Appeals Council (MAC), the issuance of decisions often far exceeds built-in timeframes (e.g., 90 days).

    We would like to know what others are experiencing – are you seeing unreasonable delays and low rates of success in the early stages?

    Additional background information:

    • Here is a link to information on the Center’s website about Medicare appeals, including Self-Help Packets for Skilled Nursing Facility, Home Health, and Outpatient Physical Therapy Denials: https://www.medicareadvocacy.org/medicare-info/medicare-coverage-appeals/
       
    • The following is an excerpt of comments submitted by the Center for Medicare Advocacy to the Senate Finance Committee re: Medicare Fraud, focusing on the performance of Medicare Administrative Contractors and the low rates of success at the initial stages of appeal (June 2012):

Since 1986 the Center for Medicare Advocacy has assisted thousands of Medicare beneficiaries and their families to challenge unfair Medicare denials. Thus, the Center has unique and extensive experience with the Medicare administrative appeals process and decision-making. Regrettably, the quality of decisions by the private entities that issue the first two levels of appeal determinations has deteriorated so significantly that these steps are all but worthless to beneficiaries. Known as Medicare Administrative Contractors (MACs), these contracted decision-makers rarely grant coverage, accurately recount the facts of the individual case, or explain the reason for their denial.

Suggesting the MACs have a rubber stamp denial rate is hardly an exaggeration. In fact, of the 2,045 redetermination decisions received by the Center last quarter for skilled nursing facility and home health care, the Medicare Contractors granted coverage in only 3 cases. Yet, our general experience is that at least half of cases that are brought to the Administrative Law Judge (ALJ) level in fact receive coverage. This cannot possibly reflect a full and fair review of the facts of each case in light of Medicare coverage criteria. Adding insult to injury, in some instances, the MACs actually take back coverage that was previously granted. This occurs, for example, in situations where some, but not all, of the services during a home health episode were previously covered by Medicare. In such cases, the MAC may not only deny an appeal for the rest of the episode, but also retract coverage that was previously provided.

  • QUALITY OF CARE COMPLAINTS:  NEW QIO PROCEDURES
     
  • On April 6, 2012, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 17, which revises and creates new procedures for the review of quality of care concerns by Quality Improvement Organizations (QIOs). Effective May 7, 2012, the new procedures apply to QIO review of the quality of services "among different cases and settings (including post-acute-care settings, ambulatory settings, and health maintenance organizations)."  In addition, CMS recently issued a Notice of Proposed Rule Making (NPRM) which discusses and, for the most part, incorporates the content of Transmittal 17.

    The procedures are complicated, but it is hoped that they will become more streamlined going forward.  However, despite the complexity of the procedures, we believe it is good that a structure for providing beneficiaries with more information about the resolution of quality of care complaints has been created.

    • Here is a link to the Center’s Weekly Alert entitled “New Procedures for Review of Quality of Care Complaints” (September 27, 2012), which contains more information about the new process, including citations: https://www.medicareadvocacy.org/2012/09/27/new-procedures-for-review-of-quality-of-care-complaints/

2. LEGISLATIVE UPATE: THE ELECTION, LAME DUCK and beyond

  • Things to look out for during the Lame Duck session of Congress after the election:
    • Extenders package – physician payment (sustainable growth rate, or SGR – 27% cut scheduled for January 2013), extension of Qualified Individual (QI) program, and extension of therapy cap exceptions.
       
    • Sequester – automatic $1.2 trillion in spending cuts over 10 years due to failure of 2011 SuperCommittee under Budget Control Act of 2011; $110 billion in 2013 sequester cuts do not include Social Security, Medicaid, SSI and certain other programs, but include a 2% provider cut in Medicare (totaling approximately $11 billion).

See website of the Leadership Council on Aging (LCAO) in coming weeks for principles, fact sheets and issue briefs on various topics, including sequester, premium support, Medicaid block grants, dual eligible integration demonstrations and Medicare beneficiary demographics and out of pocket expenses: www.lcao.org.

3. LITIGATION UPDATES

  • Bagnall v. Sebelius (Observation Status) No. 3:11-cv-01703 (D. Conn., filed 11/3/2011). On November 3rd, the Center for Medicare Advocacy filed a class action lawsuit on behalf of individuals who have been denied Medicare Part A coverage of hospital and nursing home stays because their care in the hospital was considered "outpatient observation" rather than an inpatient admission. Here is a link to the Press Release announcing the suit: https://www.medicareadvocacy.org/2011/11/press-release-class-action-lawsuit-filed-against-federal-government-to-improve-access-to-medicare-coverage/
     
  • Jimmo v. Sebelius (Improvement Standard) No. 11-cv-17 (D.Vt., filed 1/18/11). This case argues that the "Improvement Standard", which operates as a rule of thumb to terminate or deny Medicare coverage to beneficiaries who are not improving, violates substantive and procedural requirements of the Medicare statute, the Administrative Procedure Act, the Freedom of Information Act, and the Due Process Clause of the Fifth Amendment. On October 25, 2011, the presiding judge issued an order denying the government’s Motion to Dismiss. See “Federal Judge Refuses to Dismiss Medicare Beneficiaries’ Challenge to the Medicare ‘Improvement Standard’” (October 27, 2011), available at: https://www.medicareadvocacy.org/2011/10/federal-judge-refuses-to-dismiss-medicare-beneficiaries-challenge-to-the-medicare-improvement-standard-2/

    For a description of the case, see: https://www.medicareadvocacy.org/2011/07/jimmo-v-sebelius/

  • For a review of all active Center for Medicare Advocacy litigation, see: https://www.medicareadvocacy.org/litigation/active-cases.

Filed Under: Uncategorized Tagged With: Alliance Issue Brief

Primary Sidebar

Easy Access to Understanding Medicare

The Center for Medicare Advocacy produces a range of informative materials on Medicare-related topics. Check them out:

  • Medicare Basics
  • CMA Alerts
  • CMA Webinars
  • Connecticut Info & Projects
  • Health Care Stories
  • Se habla Español

Sign Up for CMA Alerts

Jimmo v. Sebelius

Medicare covers skilled care to maintain or slow decline as well as to improve.

Improvement Isn’t Required. It’s the law!

Read more.

Medicare: Build Back Better

By prioritizing Medicare beneficiaries and the health systems that serve them, we can avoid drastic national consequences. The Center for Medicare Advocacy proposes a five-part plan that will make Medicare a bulwark against the worsening health and economic challenges facing the American people.

learn more.

Latest Tweets

  • RT @johnahartford: Celebrate 35 Years of Medicare Advocacy and attend the 8th Annual National Voices of Medicare Summit & Sen. Jay Ro… https://t.co/OfBcjmtYo0, Feb 26
@CMAorg

Footer

Stay Connected:

  • Contact Us
  • Sitemap
  • Products & Services
  • Copyright/Privacy

© 2021 · Center for Medicare Advocacy