Addressing the Medicare Appeals Backlog

Abstract

When a Medicare provider is denied payment for a Medicare claim, the provider can appeal the decision to a five-level appeals system. However, the backlog of appeals at the third level of appeal is so large that statutory timeframes for decisions are not being met, and a federal judge has ordered the U.S. Department of Health and Human Services to clear the backlog by 2021. This capstone evaluates the issues causing and prolonging the backlog, offers a policy solution to address these issues, and analyzes the effectiveness, efficiency and administrative and political feasibility of the proposed solution.