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Medicare Bills Could Make It Tougher to Win Coverage Appeals

  • July 15th, 2003

Little-noticed provisions in the House and Senate Medicare bills could make it less likely that Medicare beneficiaries would prevail when they appeal Medicare coverage decisions.

Currently, Medicare appeals judges are shielded from political pressure from Medicare officials because the Social Security Administration, an independent agency, employs them. In addition, the appeals cases are heard by administrative law judges who must follow federal Medicare law.

Both of the Medicare bills pending in Congress would transfer the Medicare appeals review process from the Social Security Administration to the Department of Health and Human Services (HHS), which administers the Medicare program. Moreover, both bills provide that independent contractors, who need not be lawyers or judges, would conduct reconsiderations of initial Medicare determinations. Advocates for Medicare beneficiaries fear that these independent contractors may be unqualified to make Medicare appellate decisions, and that they would be subject to pressure to follow HHS policies rather than federal Medicare law.

Last year, Medicare beneficiaries won more than half of the appeals of reconsideration decided in hearings presided over by administrative law judges, according to the National Senior Citizens Law Center. As ElderLawAnswers previously reported, the Bush Administration has been seeking to reduce this reversal rate by replacing the judges with a new kind of hearing officer within HHS. (See "Medicare Appeals to Become Harder Under Bush Plan," 3/17/03.)

Sen. Debbie Stabenow (D-MI) has introduced a bill (S.1127) that would allow only ALJs to hold Medicare appellate hearings and would otherwise ensure the independence of ALJs.

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Last Modified: 07/15/2003

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