Interagency Effort Required to Ease ALJ Backlog

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Original story posted on: February 18, 2014

EDITOR'S NOTE: This is the second part of Oppelt's two part series on the Feb. 12 Medicare Appellant Forum held in Washington, DC.

Suggesting that an interagency effort will be required to help eliminate the backlog that has brought the Office of Medicare Hearings and Appeals (OMHA) to its knees, healthcare attorney Andrew Wachler recently indicated that the administrative law judges (ALJs) will need to do something really different.

Wachler, whose law firm has been representing clients for nearly three decades, was speaking during a live broadcast of Monitor Monday originating from the Medicare Appellant Forum last week in Washington, D.C.

“They’re going to have to do something really new and different to be able to comply with the number of requests and appeals that they have,” Wachler said during his wrap-up comments. “(Although OMHA) seems committed to do so, they can’t do it alone.”

Wachler suggested that such an interagency effort would have to include the Centers for Medicare & Medicaid Services. He also said eliminating the backlog would require the patience and efforts of the appellants and providers who have entered into the appeals’ fray or who will do so soon (appellants are providers whose appeals have reached the third of five levels of appeals). The third level brings them before an administrative law judge.

Content of the Request

The first step of the process at the third level is the request for appeals, and all requests for an ALJ hearing come to OMHA’s central operations division. Currently, it is receiving 15,000 requests a week. As a result, approximately 16 weeks after receipt of a request, staff will enter the information on your request into a database, assign it to an ALJ, and request the case file from CMS.

Although OMHA is taking steps to speed up the process, that will not happen tomorrow, and one forum presenter, Jane Cironi, provided a few examples of how providers can help make the process more efficient.

For starters, be sure you are complying with the regulatory requirements included in 42 CFR 405.1014 (http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec405-1014.pdf). As listed, requests must include:

  • The name, address, and Medicare health insurance claim number (HICN) of the beneficiary whose claim is being appealed
  • The name and address of the appellant when the appellant is not the beneficiary
  • The name and address of the designated representatives, if any
  • The document control number assigned to the appeal by the QIC, if any
  • The dates of service
  • The reasons you disagree with the QIC’s reconsideration or another determination being appealed.
  • A statement of any additional evidence to be submitted and the date it will be submitted

More comprehensive information about the above, including processing times and delays, can be found at OMHA’s website at http://www.hhs.gov/omha/index.html. At the bottom of the home page, you’ll also find a link to the slides used at the Feb. 12 appellant forum.

Tips for Submission

In addition to making the forum audience aware of the paper mess they’re in, Cironi and other presenters offered a number of tips for submitting appeal requests. A sample of these follows.

  • Consolidate as many similar claims as possible into one appeal request, and do this from the very beginning, at the first level.
  • Include all of the required items (listed above) and sign your request for appeal.
  • Submit a request for an extension of time to require a hearing with the overall request if you are filing late (beyond the 60-day receipt of the QIC reconsideration).
  • Submit additional information after assignment to an ALJ.
  • Do not submit copies of documentation already submitted at a prior level.

In addition to the above, several presenters emphasized that duplicate requests for a hearing —defined as two or more requests reflecting the same Medicare appeal number — should not be submitted. Cironi shared common reasons why duplicate requests can occur. For example, appellants can tend to:

  • Resubmit their requests because they do not hear from OMHA and assume they haven’t been received.
  • File multiple requests for a multi-beneficiary reconsideration. In other words, providers file a separate request for each beneficiary reference on the same submitted Medicare appeal number.
  • Send a courtesy copy of the ALJ request to the QIC, which then redirects it to OMHA as a misrouted original request.

Last but not least, Cironi and other presenters provided the following tips for filing:

  • Use form CMS-20034 A/B — Request for Medicare Hearing by an Administrative Law Judge (http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20034AB.pdf).
  • Prominently list the Medicare appeal number on your request, and make sure it is accurate. This number is used to establish the ALJ record.
  • Ensure that the beneficiary information you provide matches your Medicare appeal number, beneficiary name and/or HICN — and be sure to list the full HICN.
  • Include the first page of the QIC decision or prominently list the full name of the QIC.
  • Document that you provided proof of service to the other parties identified on reconsideration.
  • Use tracked mail to submit your request to OMHA’s central operations division. Be sure to get shipment tracking number so you can verify delivery.

Information Sources

About the Author

Janis Oppelt is the editorial director of MedLearn Publishing, a division of Panacea Healthcare Solutions, Inc.

Contact the Author

joppelt@panaceainc.com

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Janis Oppelt

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