February 18, 2014

Snowed Under at the ALJ But Hearings Will Continue

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EDITOR'S NOTE: Janis Oppelt was part of RACmonitor's team coverage of the ALJ Appellant Forum held in Washington on Feb. 12. This is the first of two reports by Oppelt.

It is now the day after the Medicare Appellant Forum held by the Department of Health & Human Services Office of Medicare Hearings and Appeals (OMHA), and nine or more inches of snow cover the grounds and buildings of Washington, DC, and its suburbs “inside the Beltway.”

This may not seem to be a big deal to some areas of the country, but here it means life as we know it stops: the government shuts down, schools close, and, you name it, it’s probably not functioning.

“Snowed under,” and other equally appropriate clichés including “swamped,” also describe the current situation for the OMHA’s administrative law judge (ALJ) Medicare appeals process, which is the third (of five) level available to healthcare providers and beneficiaries to challenge denied Medicare claims.

Judge Nancy Griswald, chief ALJ of OMHA, launched the appellant forum by listing its objectives, which included providing information on the agency’s initiatives to help mitigate the growing backlog as well as steps that appellants can do to make the process more efficient.

At least two times during her presentation, she emphasized—and other speakers did the same—that OMHA will continue to hold hearings—in spite of the record numbers of appeals arriving every day.

Following the Number Trail

Normally, I avoid statistics, but the following really helps to put the OMHA’s reality into perspective.

  • In FY 2009, the average time to process an appeal was 94.9 days.
  • The Centers for Medicare & Medicaid Services (CMS) permanently implemented the fee-for-service RAC Program on a nationwide basis in October 2009.
  • Between FYs 2009 and 2011, the number of days it took ALJ to process an appeal increased to 121.3.
  • In FY 2012, the number of days was 134.5 and in FY 2013 (just October, November and December), it was 329.8.

In January 2012, OMHA received 1,200 appeal requests a week, and now it is receiving 15,000 or 16,000 per week. The numbers continue to go up.

“We did anticipate an increase,” said Judge Griswold, “but this number and rapidity with which the increase happened came out of the blue. We have three workloads: Medicare Parts A and B, Medicaid dual-eligibles, and RACs. All three have been going up, but by far the most dramatic is the RAC workload.”

Like those in the forum audience, Judge Griswold said the OMHA is “quite concerned about the processing and delay times. We’re working as quickly as possible.”

Due to the substantial backlog, the OMHA implemented a deferred assignment process that affects hearing requests that it received in and after April 2013. As of January 24, 2014, Judge Griswold estimated the delay until assignment to an ALJ as 28 months.

Here’s the Punch Line: No More Physical Space

Every step of the ALJ appeals process involves paper. Currently, the OMHA has no electronic processing capabilities, although hopes to remedy that within the next few years. (See below.) Clearly, Judge Griswold’s statement that “paper management has become an issue” is an understatement.

As appeals increased, the number of paper case files also increased. To accommodate, the agency converted existing space to storage but, now, it has no more physical space for storage. Processing staff members no longer request files from CMS until they can request a hearing on ALJ docket.

Even though the number of appeals continued to increase, the OMHA’s resources (staff and budget) did not, and until FY 2014, there was no money to hire more staff. The good news is that OMHA received an 18.6 percent increase over its FY 2013 budget and will be hiring new staff members and moving toward electronic processing.

Anticipated Changes Ahead

Another speaker—Bruce Goldin, director of OMHA’s information management and systems division—provided an overview of the steps now being initiated to eliminate paper processing and bring the agency into the 21st century. He reported that OMHA has two short-term initiatives and one long-term initiative.

In the spring of 2014, Goldin expects the agency to launch the ALJ Appeal-Status Information System (AASIS) website, which will:

  • Provide public access to appeal-status information
  • Allow users to query appeal numbers for level 2 and/or 3
  • Return appeal data.

The second quarter of 2014 should bring the Medicare Appeals Template System (MATS), which is a document-generation system that uses fillable forms and data population to create individualized templates. Goldin explained that it will:

  • Improve efficiency through increased data propagation
  • Serve as the prototype for the ECAPE document, which is highlighted below.

In the long-term (possibly by the summer of 2016), the Electronic Case Adjudication and Processing Environment (ECAPE) will be launched. Goldin “hopes” this shared record system will include the following functions:

  • Case intake
  • Assignment
  • Workflow management
  • Exhibiting
  • Decision-writing
  • Closing
  • Management information.

With ECAPE, appellants will be able to do the following:

  • Electronically file hearing requests
  • Submit evidence and view file electronically
  • Send and receive communication to and from OMHA. Parts A

Next week: Steps appellants can do to make the appeals process more efficient.

About the Author

Janis Oppelt is an editor for MedLearn Publishing, a division of Panacea Healthcare Solutions, Inc.

Contact the Author

joppelt@medlearn.com

To comment on this article please go to editor@racmonitor.com

To hear our two live broadcasts from the ALJ Appellant Forum, please click here.

Janis Oppelt

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