Highlights from OMHA's Medicare Appellant Forum

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The Office of Medicare Hearings and Appeals (OMHA) recently announced that for most hearing requests received after April 1, 2013, it will be deferring assigning to Administrative Law Judges (ALJs). OMHA will continue to enter the requests into its case processing system, but then will hold them until an ALJ’s docket can accommodate them. OMHA’s announcement is available on its website at www.hhs.gov/omha.

OMHA held a forum for the public on February 12, 2014. Judge Nancy Griswold, OMHA’s Chief Administrative Law Judge, and other OMHA personnel provided an update on the ALJ hearing process. CMS provided a brief overview and update of the Medicare appeal levels 1 and 2. The Departmental Appeals Board (DAB) also provided an update on the increased work load at the level 4 appeals process. OMHA’s slide presentation is available on its website at www.hhs.gov/omha/omha_medicare_appellant_forum_presentations.pdf.

Judge Griswold highlighted the delays in the hearing process caused by the increased receipt of hearing requests in the past five years. For instance, in FY 2009, OMHA received hearing requests for 191,037 claims, and in FY 2013 for quarters 1 through 3, OMHA received hearing requests for 436,490 claims. It’s currently estimated that it will be 20 to 24 weeks before new hearing requests are entered (or “docketed”) into OMHA’s case processing system. The average processing time for appeals decided in FY 2014 is estimated to be 333.5 days.

Judge Griswold emphasized that the delayed assignment of hearing requests was not a suspension of hearings and that the ALJs were still holding hearings. During the question and answer portion of the forum, one audience member asked Judge Griswold what the statutory or regulatory authority was for deferring assigning hearing requests. Judge Griswold did not cite any authority other than case management in order to deal with the increased workload.

Besides highlighting the increased workload at OMHA, the presenters also focused on future plans to reduce the hearing request processing time. Jason Green, Director of Program Evaluation & Policy Division at OMHA, provided an overview of initiatives OMHA is exploring to address the workload. Some suggestions offered by Mr. Green to improve case processing efficiently included implementation of procedural rules and front-end reviews for procedural issues. Mr. Green also discussed alternate adjudication models, such as statistical sampling and mediation of claims.

Bruce Goldin, Director of Information Management & Systems Division at OMHA, provided updates on improving IT at OMHA, which would improve claims processing. In spring 2014, OMHA’s website will allow the public to access appeal status information such as field office assignment, ALJ assignment, appeal status, and the ALJ’s team phone number. Another IT initiative is creating an appellant portal in which hearing requests are electronically filed and evidence is electronically submitted. In the future, the appellants will be able to view the file electronically and communicate to and from OMHA.

Jane Cironi, Director of Central Operations Divisions, provided an overview of how a hearing request is processed. Ms. Cironi also discussed common filing issues and provided best practices for filing a hearing request. One common best practice reinforced during the forum was not to send duplicate copies as these are a reason for delayed case processing. The presentation contains slides regarding practice tips for filing a hearing request.

At the end of forum, Judge Griswold stated that OMHA would publish in the Federal Registrar a notice and solicitation for suggestions on how to address the problems in the adjudication process.

Ober|Kaler’s Comments

A common theme throughout the forum was that there are too many appeals at all levels of appeal and that there are not enough resources to timely adjudicate the appeals. The forum was informative in providing future initiatives to streamline the appeal process as well as practice tips to help decrease the delays. However, the forum did not provide the affected providers and suppliers answers on what to currently do while their hearing requests wait to be adjudicated. Many audience members shared that their clients are on the brink of going out of business due to the delayed adjudication process. One suggested solution by an audience member was to stay recoupment of Medicare claims until claims are fully adjudicated at the highest level, which would allow providers and suppliers to continue to operate. Providers and other stakeholders should watch for the promised Federal Register publication and take the opportunity to comment and provide suggestions.

Topics:  CMS, Healthcare, HHS, Medicaid, Medicare, OMHA

Published In: Administrative Agency Updates, Civil Procedure Updates, Health Updates

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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