Updated on: November 29, -0001

A Commitment to “Holistic Solutions” to the Appeals Backlog

By Nancy J. Griswold
Original story posted on: November 5, 2014

(Editor’s Note: The following is a transcript of Chief Administrative Law Judge Nancy J. Griswold’s recent appearance on Monitor Mondays, in which she comments on the recent Medicare appellant’s forum and the continuing backlog of Medicare appeals.)

Hello Chuck and thanks for having me on the program again. I appreciate the opportunity to update your listeners on happenings from last week’s forum.

To address Drew’s (Andrew Wachler) question about our average processing times, I want to clarify that the times posted are from receipt of request for hearing through decision letter mailed. We know 514 days for September is not where we want to be, but it does get the decision out the door.  

As you know, this was our second Medicare appellant’s forum, and I want to emphasize our belief that in today’s environment of high appeal receipts and an increasing pending level, it is critical that we continue to be transparent with our stakeholders – not only about the challenges that we are facing, but also how we plan to address those challenges.

In addition to representatives from the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council, we were privileged to be joined at this forum by Deputy Secretary Bill Corr, who reiterated the department’s commitment to finding “holistic solutions” to the appeals backlog — and by that I mean that solutions (that) must involve all three agencies involved in the appeals process, CMS, OMHA (the Office of Medicare Hearings and Appeals), and the Medicare Appeals Council. The presence of all three agencies at the forum signaled their recognition that they are also committed to being part of the solution.  

On workloads at OMHA, suffice it to say that appeals remain high at 14,000 per week, which is slightly down from our high of 16,000, but still many more than we can handle given our current resource levels.  

Now to some updates on our initiatives to help manage our pending workloads. OMHA recognizes that there is no one approach that will provide an overall solution.  

Accordingly, OMHA continues to focus on developing initiatives based on a holistic approach. The goal is to develop multi-level initiatives working hand-in-hand to address OMHA’s workload and backlog issues. There really are two issues here — handling the large number of appeals already pending at OMHA, but also positioning OMHA for the future so that it can handle its workload of incoming receipts in a timely manner.

Adjudication expansion is the first step in preparing OMHA to handle its receipt base, and I am pleased to report that I am speaking to you today from our new field office in Kansas City, giving us a long-awaited presence in the Central Time Zone.  

  • I am here to meet with managers and staff this week and to impress upon them the importance of their work here at OMHA, and how that work is a public service to the Medicare community – both providers and suppliers and the beneficiaries that they in turn serve.
  • This is our fifth office and the first new office that has been added since OMHA opened its doors in 2005. The Kansas City Field Office opened on Aug. 25, 2014, and the first hearing was held in Kansas City on Sept. 16, with the first decision being issued on Sept. 26. If the president’s budget is passed in 2015, OMHA plans to expand the Kansas City office to accommodate a total of 18 administrative law judge (ALJ) teams next spring.
  • When fully staffed, the ALJs in Kansas City will be able to adjudicate 18,000 additional appeals per year.  

There are also a number of efforts to resolve cases at lower levels of the appeals process.

  • CMS reported on its efforts to engage providers, suppliers, and contractors to resolve policy questions that are resulting in denials (as an example, earlier this year, CMS issued a clarification to its durable medical equipment Medicare Administrative Contractor concerning proof of delivery.)
  • CMS also reported that it is looking at ways to increase its engagement with providers at the first two levels of the appeals process.  

Both OMHA and CMS have also put in place several initiatives which should begin to reduce the backlog of pending cases.  

  • The use of statistical sampling with appellant consent, which we had hoped would provide a way to adjudicate large numbers of claims more quickly before an ALJ, has not been as widely utilized as we had hoped — and we believe this is largely because of the limited timeframes for grouping of claims for the universe. We are also looking at ways to amend the pilot to make it more attractive to appellants. Changes to this pilot will probably be announced in January.
  • We have also implemented a voluntary settlement conference facilitation pilot. We had our first settlement conference facilitation, which unfortunately did not result in a settlement, but did result in a number of lessons learned, which we will be incorporating into our next facilitation. We also have a number of requests pending and will keep stakeholders posted on our progress. We continue to believe that this program provides a viable means for resolution of claims at the ALJ level, and (we) will continue to offer the program as an additional resource for appellants.   
  • And of course, CMS provided an administrative resolution option that addressed the largest category of provider appeals, accounting for more than 50 percent of all pending appeals at OMHA: Medicare Part A inpatient status denials. The administrative resolution provided a mechanism for providers to avoid the cost of appeals and re-billing. This also helps us address the appeals backlog, and Deputy Secretary Corr reported at the forum that through last Wednesday, the administrative settlements that CMS received will reduce appeals at OMHA by more than 110,000. 

We are also implementing several IT initiatives to support our backlog reduction efforts.

  • We recognize that IT initiatives are not the sole solution, but they must be part of the solution by equipping us to effectively and efficiently manage our workload. 
  • The ALJ Appeal Status Information System (AASIS) website is an interim solution until we have ECAPE implemented. It will provide appellants with the ability to access basic appeal information such as dates appeals are received, appeal status, field office/ALJ assignment with contact info, etc.

We had hoped to have this website in place earlier this year, but experienced some programming delays. We now project that the website will be rolled out by the end of the calendar year. It will be announced and accessed through the OMHA website.

The Electronic Case Adjudication and Processing Environment (ECAPE):

  • OMHA has been actively working toward an Electronic Case Processing Environment (ECAPE) for many years, and I am pleased to announce that the development contract will be awarded January 2015, with our first release scheduled for fall of 2015.
  • And to answer David’s (David Glaser) question, ECAPE will have a portal which will allow our appellants to view the official record and page numbers that the judge is using at the hearing. In the interim, we will just have to stick with referencing the provider, date of service, and type of record. Your page numbers may help, but they often don’t match with the official page number.   

And finally, we have added a contract scanning initiative this year.

  • We expect to award the scanning contract by the end of the calendar year.  
  • We will scan the unassigned RFHs and associated documents. 
  • This will allow us to more effectively manage our pending workload and transition into an electronic environment more quickly once ECAPE is implemented.

As one last update, I am pleased to tell you the OMHA’s request for information has received final clearance and will be published in the Federal Register very soon. This RFI will provide you an opportunity to comment on our efforts thus far and to submit additional suggestions for improving the ALJ appeals process.  

OMHA knows more needs to be done and will continue to engage the appellant community and pursue additional initiatives, and you will see more from these efforts in the coming months. OMHA is committed to eliminating these delays. Again, I recommend that you watch OMHA’s website for updates on existing programs as well as announcements concerning new programs. As we develop new guidance and programs, we will share that information with you via OMHA’s website.

OMHA’s website is available at www.hhs.gov/omha.

As Deputy Secretary Bill Corr said, “the backlog emerged quickly, but not overnight, and it will not go away overnight but with the right mix of initiatives and the addition of new resources to get the job done. OMHA and HHS leadership are confident that we can continue making meaningful progress, and that OMHA will be able to manage the appeals process as efficiently as has been done in the past.”

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