The Medicare appeals rule published January 17, 2017 separated work requiring an administrative law judge’s hearing from specified matters an attorney adjudicator could handle. These included eligible decisions without hearings, dismissals following withdrawn hearing requests, specified remands and dismissal reviews. HHS projected that the change could redirect approximately 24,500 appeals each year. Redirection was the estimate; completed decisions were not the reported result. [2016-32058]

The earlier proposal gives the starting workload. Published July 5, 2016, it recorded more than 750,000 pending appeals on April 30 at the Office of Medicare Hearings and Appeals. Annual adjudication capacity stood at 77,000 appeals, with another 15,000 in annual capacity expected by the end of fiscal 2016. The expected addition was a forecast in that document. [2016-15192]

The final publication supplied a later snapshot: more than 650,000 appeals pending on September 30, 2016, and approximately 92,000 appeals of annual capacity, based on a maximum sustainable 1,000 per judge’s team. The two snapshots have different dates. They cannot establish that the January rule reduced the backlog, and they do not count distinct beneficiaries or payments. [2016-32058][2016-15192]

March 20, 2017 was the scheduled effective date. The final rule also allowed selected Medicare Appeals Council decisions to become precedent through designation by the Departmental Appeals Board chair, using factors such as recurring legal issues and public interest. Neither delegation of work nor selective precedent made every case interchangeable. These provisions describe administrative design, not demonstrated implementation. [2016-32058]

Source documents

  1. Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedureshttps://www.govinfo.gov/content/pkg/FR-2017-01-17/html/2016-32058.htm
  2. Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedureshttps://www.govinfo.gov/content/pkg/FR-2016-07-05/html/2016-15192.htm