Senate Finance Committee Issues Report on AFIRM Act
Excerpts of the report follow:
I. LEGISLATIVE BACKGROUND
Background and need for legislative action
Within HHS, the
The
CMS hires a variety of private review contractors to identify improper
Despite CMS's efforts, the improper payment rate in the
Providers and beneficiaries are able to appeal Part A and Part B improper payment determinations made by MACs or other
[Footnote 1: Improper payment determinations by other
[Footnote 2: QICs do not process claims or conduct audits--they are only involved in the appeals process. QIC conduct independent reconsiderations of
Although some beneficiaries appeal payment decisions, the majority of appellants (85 percent) are providers. Two percent of these providers accounted for nearly one-third of all ALJ appeals in FY 2010. And, some provider-appellants filed many more appeals than others. On average, providers filed six appeals each, but 96 providers filed at least 50 appeals each, and one provider filed over 1000 appeals. 3 [Footnote] The vast majority of RA audits are not appealed (in 2011, only 6.7 percent of RA improper payment determinations were appealed).
[Footnote 3: Improvements are Needed at the Administrative Law Judge Level of Medicare Appeals, HHS-OIG, OEI-02-10-00340 (
Although most RA audit decisions are not appealed, the expansion of RA audits has coincided with the rise in appeals, which has contributed to the backlog at OMHA. At the time of this report, there are so many appeals being filed that the
The HHS-OIG report found that some ALJs were more likely than others to make decisions that were fully favorable to appellants. Among the 66 ALJs, the fully favorable rate ranged from 18 to 85 percent. HHS-OIG reported that ALJ staff stated that different philosophies among ALJs contribute to the variation in fully favorable rates. ALJ staff said that given the same facts and the same applicable
This bill addresses the primary causes of the increase in appeals and the backlog itself. First, the bill will improve CMS oversight of audit contractors and require better coordination between auditors and CMS. The bill will ensure that all parties receive transparent data regarding review practices and appeal outcomes at each level of review. Second, the bill will require that CMS create new incentives to improve auditor accuracy. It will also require that CMS create an independent Ombudsman for Medicare Reviews and Appeals to assist in resolving complaints by appellants and those considering appeal. Finally, the bill will make needed reforms to and increase funding for the
process for multiple pending claims with similar issues to be settled as a unit, rather than as individual appeals.
The Committee recognizes the need to address this serious backlog to ease the burden on physicians and other health care providers and on beneficiaries.
II. EXPLANATION OF THE BILL
The present law applicable to sections 2 through 6, and 8 of the bill is discussed at the beginning of section II, part A (there are no provisions in present law for sections 1, 7 and 9). Part A then explains the provisions of each section separately. The present law and provisions of sections 10, 11, 12, and 13 of the bill are discussed in section II, parts B, C, D, and E respectively.
III. BUDGET EFFECTS OF THE BILL
A. COMMITTEE ESTIMATES
In compliance with paragraph 11(a) of Rule XXVI of the Standing Rules of the
The bill is estimated to have the following effects on federal budget receipts for fiscal years 2016-2025:
Insert graphic folio 21 SR177.001
Summary
The bill would authorize the appropriation of
For this estimate, CBO assumes that the legislation will be enacted near the beginning of fiscal year 2016 and that the amounts specified will be appropriate in that year. Enacting the Audit & Appeals Fairness, Integrity, and Reforms in Medicare Act of 2015 would affect direct spending or revenues; therefore, pay-as-you-go procedures apply. The bill would not impose intergovernmental or private sector mandates as defined in the Unfunded Mandates Reform Act and would impose no costs on state, local, or tribal governments. The annual estimated budgetary impact of the Audit & Appeals Fairness, Integrity, and Reforms in Medicare Act of 2015 is shown in the table above.
B. BUDGET AUTHORITY
Budget authority
In compliance with section 308(a)(1) of the Congressional Budget and Impoundment Control Act of 1974 (Budget Act') the Committee states that the bill as reported involves increased budget authority (see table in Part A., above).
Tax expenditures
In compliance with section 308(a)(1) of the Budget Act, the Committee states that the bill does not involve increased tax expenditures.
C. CONSULTATION WITH CONGRESSIONAL BUDGET OFFICE
In accordance with section 403 of the Budget Act, the Committee advises that the
IV. VOTES OF THE COMMITTEE
In compliance with paragraph 7(b) of rule XXVI of the Standing Rules of the
Final Passage of the Audit & Appeals Fairness, Integrity, and Reforms in Medicare Act of 2015 or the AFIRM Act--approved by voice vote.
V. REGULATORY IMPACT AND OTHER MATTERS
A. REGULATORY IMPACT
Pursuant to paragraph 11(b) of rule XXVI of the Standing Rules of the
Impact on individuals and businesses, personal privacy and paperwork
The bill is not expected to impose additional administrative requirements or regulatory burdens on individuals. The bill is expected to reduce administrative requirements and regulatory burdens on some businesses.
The provisions of the bill do not impact personal privacy.
B. UNFUNDED MANDATES STATEMENT
This information is provided in accordance with section 423 of the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 104-4).
The Committee has determined that the bill does not contain any private sector mandates. The Committee has determined that the bill contains no intergovernmental mandate.
VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED
In the opinion of the Committee, it is necessary in order to expedite the business of the
The full text of the report is found at: http://thomas.loc.gov/cgi-bin/cpquery/30?cp114:temp/~cp114EbuAM&sid=cp114EbuAM&item=30&sel=TOCLIST&l_f=151&l_file=list/cp114cs.lst&l_b=101&l_file=list/cp114cs.lst&report=sr177.114&hd_count=50&4&&&l_t=184&&&
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