Legal Experts Offer Analysis of New Proposed Rule on the MA Appeals Process in AIS Newsletter

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A CMS proposal to streamline the Medicare Advantage appeals process could benefit health plans, experts tell Atlantic Information Services’ Medicare Advantage News.

A new proposed rule would streamline the process for Medicare Advantage (MA) and Part D payment and coverage determination appeals, Atlantic Information Services, Inc.’s (AIS) Medicare Advantage News (MAN) reports in its July 21 issue. Using a tripartite approach, the Centers for Medicare & Medicaid Services (CMS) will address the current claims backlog and the rising number of appeals requests by increasing the number of available administrative law judges, taking administrative actions to reduce the number pending appeals and backlog, and proposing new legislation to reform the system.

Attorney Kelli Back tells MAN the “most engaging” part of the rule may be the proposal to make certain MAC decisions set precedent. “This has the potential to not only create some predictability at that level, but to allow [Recovery Audit Contractors] and Medicare Advantage plans to have some additional guidance to use in making determinations (and providers in billing for services) that could potentially cut down on the amount of appeals and overturns.”

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About Medicare Advantage News
Medicare Advantage News is the health care industry’s #1 source of timely news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in this hotly contested area of health insurance. Published biweekly since 1994 (when it was Medicare+Choice), the newsletter exists to help plans boost revenues, increase enrollees, cut costs and improve outcomes in Medicare Advantage and Medicaid managed care. Visit for more information.

About AIS
Atlantic Information Services, Inc. (AIS) is a publishing and information company that has been serving the health care industry for nearly 30 years. It develops highly targeted news, data and strategic information for managers in hospitals and health systems, health insurance companies, medical group practices, purchasers of health insurance, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, databases, websites, looseleafs, strategic reports, directories, webinars, virtual conferences and training programs. Learn more at

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Jill Brown, Executive Editor
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since: 01/2011
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Atlantic Information Services, Inc.

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