OMHA Announces Two New Programs to Process Administrative Law Judge (ALJ) Hearings More Efficiently

by Baker Ober Health Law
Contact

Earlier this year, the Office of Medicare Hearings and Appeals (OMHA) announced that for most hearing requests received after April 1, 2013, it will be deferring assignment of ALJs. OMHA’s announcement is available on its website at www.hhs.gov/omha. We published an article titled “Highlights from OMHA’s Medicare Appellant Forum,” that described OMHA’s forum for the public on February 12, 2014, in which Judge Nancy Griswold, OMHA’s Chief Administrative Law Judge, and other OMHA personnel provided an update on the ALJ hearing process.

At this forum, Jason Green, Director of Program Evaluation & Policy Division at OMHA, provided an overview of initiatives OMHA was exploring to address the workload. Some suggestions offered by Mr. Green to improve case processing included alternate adjudication models, such as statistical sampling and mediation of claims. Recently, OMHA announced that it implemented the following proposals: the Settlement Conference Facilitation Pilot Program and the Statistical Sampling Initiative. Below is a summary of both programs.

The Settlement Conference Facilitation Pilot Program

This program is a pilot alternate dispute resolution program that OMHA designed to bring the appellant and CMS together to discuss a potential mutually agreeable resolution of the claims appealed to the ALJ hearing level of the Medicare claim appeals process. The process involves a settlement conference facilitator (Facilitator), who is an employee of OMHA and uses mediation principles to assist the appellant and CMS to reach a mutually agreeable resolution. The Facilitator does not make official determinations on the merits of the claims at issue. The Facilitator also does not act as a factor finder. If the appellant and CMS reach a resolution, they will sign a settlement document drafted by the Facilitator reflecting the agreement. Part of the agreement includes the dismissal of the ALJ hearing requests covered by the settlement.

OMHA’s website for the Settlement Conference Facilitation Pilot Program contains a list of eligibility requirements to participate in this process. Some of these requirements include that the appellant must be a Medicare provider or supplier, and that the amount of each individual claim must be less than $100,000. To participate in this program, the appellant must complete a written request for a Settlement Conference Facilitation and fill out a spreadsheet providing detailed information regarding the claims that are subject to the request. Rejection of a request for a Settlement Conference Facilitation is not appealable.

OMHA’s Settlement Conference Facilitation Pilot Fact Sheet Fact [PDF] answers additional industry questions. This program applies only to unassigned ALJ hearing requests filed in 2013. The Fact Sheet states that settlement agreements are not appealable. Also, if the parties do not reach a settlement, the appealed claim(s) will return to the ALJ hearing process for adjudication in the order the request for hearing was received.

For more information on the Settlement Conference Facilitation Pilot Program, please visit OMHA’s website at www.hhs.gov/omha/settlement_conference_facilitation_pilot.html.

The Statistical Sampling Initiative (SSI)

The SSI provides appellants with an option to address large volumes of claim disputes at the ALJ hearing level by using statistical sampling to draw a random sample from a universe of claims and extrapolate the sample’s results to the entire universe of claims. The appellant may request statistical sampling or OMHA may offer statistical sampling. An OMHA employee, called a statistical sampling coordinator, will serve as the central point of contact for the appellant.

An ALJ will conduct a pre-hearing conference to confirm consent for the statistical sampling and address other matters. The ALJ will issue a pre-hearing conference order, which becomes binding, and the appellant’s appeals will be combined into a single appeal that is assigned to a new ALJ for hearing on the sample units selected by the OMHA statistical expert. This trained and experienced statistical expert will conduct the statistical sample, and this person will develop the appropriate sampling methodology in accordance with Medicare guidance, and randomly select the sample units. The ALJ will review the sample and make findings and issue a decision based on this sample. After the ALJ conducts the hearing and issues a decision, the decision on the sample units will be extrapolated to the universe of claims by a CMS contractor and the decision will be effectuated based on the extrapolated amount.

OMHA’s website for the SSI contains a list of appeal eligibility requirements. One of the requirements includes having a minimum of 250 claims that fall into one of the three listed categories:
• Pre-payment claim denials;
• Post-payment (overpayment) non-Recovery Audit Contractor (RAC) claim denials; or
• Post-payment (overpayment) RAC claim denials from one RAC.

OMHA’s Statistical Sampling Fact Sheet [PDF] answers additional questions that Medicare providers and suppliers may inquire. OMHA is conducting statistical sampling for appeals currently assigned to ALJs, or appeals currently being assigned by OMHA Central Operations (which includes appeals filed between April 1, 2013 and June 30, 2013). An appellant is permitted to request a statistical sampling for claims from multiple providers or suppliers only if these are owned by a single entity that agrees to the requirements for payment.

For more information on the Settlement Conference Facilitation Pilot Program, please visit OMHA’s website at www.hhs.gov/omha/statistical_sampling_initiative.html.

Ober|Kaler's Comments

OMHA announced these proposals at its forum on February 12, 2014. By implementing these two proposals less than six months after publicly announcing them, OMHA shows that is listening to providers’ and suppliers’ frustrations with the appeals backlog. OMHA is taking steps in the right direction to reduce the backlog; however, these proposals are currently limited to a small subset of appeals and, therefore, are not likely to have an immediate impact on the appeals backlog. Providers and suppliers should take advantage of these two new proposals to streamline their appeals processes when they are eligible to participate.

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.

© Baker Ober Health Law | Attorney Advertising

Written by:

Baker Ober Health Law
Contact
more
less

Baker Ober Health Law on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Privacy Policy (Updated: October 8, 2015):
hide

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.

Security

JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at info@jdsupra.com. In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at: info@jdsupra.com.

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.