October 29, 2014

No Quick Fix for ALJ Appeals Backlog — But OMHA Reports Signs of Progress

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On Oct. 29, the U.S. Department of Health and Human Services Office of Medicare Hearings and Appeals (OMHA) held its second appellant forum of the year to address the status of the backlog and processing delay of administrative law judge (ALJ) appeals – which represent the third of five levels of appeal available to healthcare providers and beneficiaries to challenge denied Medicare claims. The primary purpose of this forum was to allow OMHA to provide an update on the status of the actions it has taken, and what actions it plans to take in the future. 

In her opening remarks at the forum, Nancy Griswold, OMHA’s chief ALJ, acknowledged that no one approach will solve the current problem – which is why OMHA ALJs and their teams are pursuing “holistic” solutions. The Centers for Medicare & Medicaid Services (CMS) and the Departmental Appeals Board (DAB) also are working with OMHA to find other ways to reduce the burden on appellants and streamline the appeals process, she said.

Judge Griswold spent a good deal of time reviewing information presented during the February forum related to the mission, history, and changing landscape of OMHA since its 2005 inception – and since 2009, when CMS implemented the Recovery Auditor program. Specifically, during the 2009 fiscal year, the average time it took to process an appeal was 94.9 days; yet in the last quarter of the 2013 fiscal year, it was 329.8 days (a number that is still climbing).

However, Griswold and her colleagues also reported on several positive developments. For example, Congress increased OMHA’s 2014 budget by 18.6 percent, which enabled it to “increase its adjudication capacity” by establishing a new field office of eight teams in Kansas City in February 2014. If the 2015 budget is approved, OMHA will add 10 more teams to address appeals in that region.

As previously noted, the budget increase also allowed the office to initiate a “holistic approach to address our workload and pending appeals,” Griswold noted – and that approach includes improvements and information technology (IT) upgrades that are converting OMHA’s processes from paper to electronic. 

In another example, a development contract will be awarded in January 2015 for a system called the Electronic Case Adjudication Processing Environment (ECAPE), which should be up and running by the summer of 2015. The functionality of this system will cover case intake and assignment, workflow management, and shared records. 

Jason Green, director of OMHA’s Program Evaluation and Policy Division, also reported on two pilot projects underway: 

  • Statistical sampling: This is a pilot intended to provide appellants with an option for addressing large volumes of claim disputes at the ALJ hearing level. A random sample is drawn from a universe of claims and the results of the sample are extrapolated to the entire universe of claims. An ALJ then reviews the sample and makes determinations. (Comprehensive details and eligibility requirements about this pilot can be found online at http://www.hhs.gov/omha/statistical_sampling_initiative.html.)
  • Settlement Conference Facilitation: This pilot alternative dispute-resolution process brings the appellant and a CMS representative together to discuss the possibility of a mutually agreeable resolution for claims appealed to the ALJ hearing level. If a resolution is reached, the facilitator drafts a settlement document, which is signed by CMS and the appellant. As part of the agreement, the requests for an ALJ hearing for the claims covered by the settlement are dismissed. (For more on this, go online to http://www.hhs.gov/omha/settlement_conference_facilitation_pilot.html.)

Green also reported that OMHA will be monitoring the performance of these pilots and, if they are successful, it will roll them out nationally as funding allows. 

As stated above, CMS also has developed a few of its own initiatives to reduce the current number of appeals that reach OMHA. Arrah Tabe-Bedward, director of the Medicare Enrollment and Appeals Group, reported that appellants attending the February forum said that the first opportunity they had to interact with adjudicators was at the ALJ level. To understand the process, and to resolve more cases at the lower levels and reduce number of cases that flow up, these individuals indicated they would like an opportunity to interact with the adjudicators.

Tabe-Bedward reported that CMS is “trying to incorporate an opportunity for such a dialogue,” but the plan is still in the early planning stages. 

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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PROGRAM NOTE:

Judge Griswold will appear on Monitor Mondays on Monday, November 3, 10 AM ET. Register to listen.

 

Janis Oppelt

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