Medicare Appeals: Disparity between Requirements and Responsible Agencies' Capabilities
GAO-03-841
Published: Sep 29, 2003. Publicly Released: Oct 29, 2003.
Skip to Highlights
Highlights
Appellants and others have been concerned about the length of time it takes for a decision on the appeal of a denied Medicare claim. In December 2000, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), required, among other things, shorter decision time frames. BIPA's provisions related to Medicare appeals were to be applied to claims denied after October 1, 2002, but many of the changes have not yet been implemented. GAO was asked to evaluate whether the current Medicare appeals process is operating consistent with BIPA's requirements and to identify any barriers to meeting the law's requirements.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | The Secretary of Health and Human Services and the Commissioner of SSA should create an interagency steering committee with representatives from CMS, the carriers, OHA, and the MAC to serve as an advisory body to the Secretary of Health and Human Services and the Commissioner of SSA responsible for making administrative processes, such as file tracking and transfer, compatible across all appeals bodies. |
Closed – Not Implemented
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 mandated that SSA transfer its responsibility for adjudicating Medicare appeals to HHS no sooner than July 1, 2005, and no later than October 1, 2005, thus obviating the need for an interagency steering committee. Implementation of the transfer has begun, as scheduled.
|
| Social Security Administration | The Secretary of Health and Human Services and the Commissioner of SSA should create an interagency steering committee with representatives from CMS, the carriers, OHA, and the MAC to serve as an advisory body to the Secretary of Health and Human Services and the Commissioner of SSA responsible for making administrative processes, such as file tracking and transfer, compatible across all appeals bodies. |
Closed – Not Implemented
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 mandated that SSA transfer its responsibility for adjudicating Medicare appeals to HHS no sooner than July 1, 2005, and no later than October 1, 2005, thus obviating the need for an interagency steering committee. Implementation of the transfer has begun, as scheduled.
|
| Department of Health and Human Services | The Secretary of Health and Human Services and the Commissioner of SSA should create an interagency steering committee with representatives from CMS, the carriers, OHA, and the MAC to serve as an advisory body to the Secretary of Health and Human Services and the Commissioner of SSA responsible for negotiating responsibilities and strategies for reducing the backlog of pending cases, especially at OHA and the MAC, and establish the priority for adjudicating pre-BIPA cases relative to BIPA-governed cases. |
Closed – Not Implemented
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 mandated that SSA transfer its responsibility for adjudicating Medicare appeals to HHS no sooner than July 1, 2005, and no later than October 1, 2005, thus obviating the need for an interagency steering committee. Implementation of the transfer has begun, as scheduled. SSA has committed to completing all of its pending workload.
|
| Social Security Administration | The Secretary of Health and Human Services and the Commissioner of SSA should create an interagency steering committee with representatives from CMS, the carriers, OHA, and the MAC to serve as an advisory body to the Secretary of Health and Human Services and the Commissioner of SSA responsible for negotiating responsibilities and strategies for reducing the backlog of pending cases, especially at OHA and the MAC, and establish the priority for adjudicating pre-BIPA cases relative to BIPA-governed cases. |
Closed – Not Implemented
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 mandated that SSA transfer its responsibility for adjudicating Medicare appeals to HHS no sooner than July 1, 2005, and no later than October 1, 2005, thus obviating the need for an interagency steering committee. Implementation of the transfer has begun, as scheduled. SSA has committed to completing all of its pending workload.
|
| Department of Health and Human Services | The Secretary of Health and Human Services and the Commissioner of SSA should create an interagency steering committee with representatives from CMS, the carriers, OHA, and the MAC to serve as an advisory body to the Secretary of Health and Human Services and the Commissioner of SSA responsible for establishing requirements for reporting specific and comparable program and performance data to CMS, SSA, and HHS so that management can identify opportunities for improvement, and determine the resource requirements necessary to ensure that all appeals bodies will be able to meet BIPA's requirements. |
Closed – Not Implemented
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, mandated that SSA transfer its responsibility for adjudicating Medicare appeals to HHS between July 1, 2005, and October 1, 2005, thus obviating the need for an interagency steering committee.
|
| Social Security Administration | The Secretary of Health and Human Services and the Commissioner of SSA should create an interagency steering committee with representatives from CMS, the carriers, OHA, and the MAC to serve as an advisory body to the Secretary of Health and Human Services and the Commissioner of SSA responsible for establishing requirements for reporting specific and comparable program and performance data to CMS, SSA, and HHS so that management can identify opportunities for improvement, and determine the resource requirements necessary to ensure that all appeals bodies will be able to meet BIPA's requirements. |
Closed – Not Implemented
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 mandated that SSA transfer its responsibility for adjudicating Medicare appeals to HHS between July 1, 2005, and October 1, 2005, thus obviating the need for an interagency steering committee. Implementation of the transfer has begun, as scheduled. Consequently, there is no need for SSA to take action.
|
Full Report
Office of Public Affairs
Topics
Appeals processClaims processingDecision makingHealth care programsInsurance claimsInteragency relationsManaged health careMedical expense claimsMedicareMedical information systemsNoncomplianceProgram coordinationTimeliness