Medicare Appeals: Disparity between Requirements and Responsible Agencies' Capabilities Page: 2 of 51
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' Accountability* Integrity* Reliability
Highlights of GAO-03-841, a report to the
Committee on Energy and Commerce,
House of Representatives
Why GAO Did This Study
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
GAO recommends that the
Secretary of HHS and the
Commissioner of SSA more closely
coordinate their efforts to improve
administrative processing, develop
strategies for reducing the backlog
of pending cases, and establish
data requirements to facilitate the
successful implementation of
BIPA's mandated changes. HHS
and SSA agreed that inefficiencies
in the appeals process require
attention and that the process
would benefit from better
To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Leslie G.
Aronovitz at (312) 220-7600.
Disparity between Requirements and
Responsible Agencies' Capabilities
What GAO Found
BIPA demands a level of performance, especially regarding timeliness, that
the appeals bodies-the contract insurance carriers responsible for the first
two levels of appeals, the Social Security Administration's (SSA) Office of
Hearings and Appeals (OHA), and the Department of Health and Human
Services (HHS) Medicare Appeals Council (MAC)-have not demonstrated
they can meet. While the carriers have generally met their pre-BIPA time
requirements, in fiscal year 2001, they completed only 43 percent of first
level appeals within BIPA's 30-day time frame. In addition to average
processing times more than four times longer than that required by BIPA,
OHA and the MAC-the two highest levels of appeal-have accumulated
sizable backlogs of unresolved cases. Delays in administrative processing
due to inefficiencies and incompatibility of their data systems constitute 70
percent of the time spent processing appeals at the OHA and MAC levels.
Average Time Spent in Each Stage of Processing for Cases Adjudicated by OHA and the
MAC in Fiscal Year 2001
Office of Hearings and Appeals
Administrative processing and adjudication
7 months 3 months 4 months
Appellant Case materials Case Appeals
submits received by materials body issues
request for local hearing assigned to decision
review office legal staff
Medicare Appeals Council
Administrative processing and adjudication
3 months 3 months 11 months 4 months
Appellant The MAC Case Case Appeals
submits requests materials materials body issues
request for case files received assigned to decision
review legal staff
Sources: OHA and the MAC.
The appeals bodies are housed in two different agencies-HHS and SSA.
The lack of a single entity to set priorities and address operational
problems-such as incompatible data and administrative systems-at all
four levels of the process has precluded successful management of the
appeals system as a whole. Uncertainty about funding and a possible transfer
of OHA's Medicare appeals workload from OHA to HHS has also complicated
the appeals bodies' ability to adequately plan for the future.
United States General Accounting Office
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United States. General Accounting Office. Medicare Appeals: Disparity between Requirements and Responsible Agencies' Capabilities, report, September 29, 2003; Washington D.C.. (digital.library.unt.edu/ark:/67531/metadc292899/m1/2/: accessed January 20, 2019), University of North Texas Libraries, Digital Library, digital.library.unt.edu; crediting UNT Libraries Government Documents Department.