Council for Medicare Integrity Urges Congress to Pass AFIRM Act

Reform Needed to Repair Besieged Medicare Appeals Process

WASHINGTON–(BUSINESS WIRE)–#AFIRM–Today, the Council for Medicare Integrity (CMI) is asking Members of
Congress to take swift action to pass the Audit and Appeals Fairness,
Integrity and Reforms in Medicare (AFIRM) Act. Passed
by the Senate Finance Committee last year
, AFIRM seeks to make
urgently needed programmatic changes to help address the backlog of
560,663 cases waiting for review in the U.S. Department of Health and
Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA)

The AFIRM Act would ensure active steps are taken to address the backlog
by sending claims back to the first level of appeal when new evidence is
introduced later in the process. It would also create Medicare
Magistrates to perform reviews and render decisions on certain types of
cases, and ensure fairness by requiring that all parties involved be
notified in advance of a hearing to allow for participation of all

“Some Medicare providers continue to actively seek to collect millions
in improper payments from the program,” said CMI spokesperson Kristin
Walter. “They flooded the system with meritless appeals, causing the
backlog, while inexplicably laying blame at the feet of those mandated
by Congress to ensure that providers adhere to Medicare billing policy.”

The current backlog of appeals has been widely credited to a small
number of Medicare providers that dispute nearly every claim denial at
the Administrative Law Judge (ALJ) level in an attempt to game the
system and secure higher payouts. Unlike other levels of appeal in the
process, ALJs have broad discretion and do not have to follow Medicare
policy – spawning an epidemic of “frequent
filer” providers
. According to Chief ALJ Nancy
, 51 percent of appeals filed in 2015 were filed by the same
five appellants.

“The Recovery Audit Contractor Program has been proven a successful tool
in identifying and returning improper Medicare payments and has an
independently-validated accuracy rate of more than 95 percent,” said
Walter. “It’s time to put safeguards in place to prevent providers from
flooding the appeals process. It’s time to pass AFIRM to shore up the
program and move backlogged cases through more efficiently.”

While the AFIRM Act addresses several issues facing the struggling
Medicare appeals process, CMI recommends some additional safeguards to
further promote expediency and prevent future backlogs, specifically:

  • Inclusion of an appeals filing fee, refundable if a provider wins its
    appeal, as championed by the President’s Budget, the HHS Secretary and
    Chief ALJ;
  • Penalties for providers who fail to bill a claim within 3 months of
    the date of service;
  • Requirements recommended by Congress that ALJs make decisions
    consistently and in accordance with Medicare policy; and,
  • Expedition of claims where no facts are disputed.

“We applaud members of the House and Senate who have championed the
AFIRM Act,” said Walter. “This is an important priority to CMI, even
with HHS recently noting that RACs are not, and have never been the
primary source for the backlog. We urge Congress to focus their
immediate attention to this important issue after the election. The
Medicare program and American seniors are counting on it.”

Congress mandated the creation of the Recovery Audit Contractor (RAC)
Program to review Medicare claims, identify billing errors and return
mis-billed funds back to the Medicare Trust Funds. Since the program
began in 2009, RACs have returned more than $10 billion in improper
payments and more than $800 million in underpayments back to providers.
Recovery auditing has been credited with extending the life of the
Medicare program by two full years.

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About the Council for Medicare Integrity

The Council for Medicare Integrity is a 501(c)(6) non-profit
organization. The Council’s mission is to educate policymakers and other
stakeholders regarding the importance of healthcare integrity programs
that help Medicare identify and correct improper payments.


For the Council for Medicare Integrity
Kristin Walter, (202)