On November 5, 2014, the Office of Medicare Hearings and Appeals (OMHA), a division of the Office of the Secretary of the Department of Health and Human Services, published in the Federal Register a Request for Information soliciting suggestions for addressing the significant growth in the number of requests for hearings conducted by Administrative Law Judges (ALJs) as well as the backlog of pending cases. Stakeholders may submit comments through December 5, 2014.

OMHA administers the third level of Medicare appeals. Importantly, this is the first level of review conducted outside of CMS and is the only level of review before an ALJ. Beginning in 2012, OMHA began experiencing a sharp increase in workload due to a significant increase in the number of claims appealed to OMHA. The increase in appeals workload stemmed from several changes to Medicare claim reviews and appeals processes, including: (1) Medicaid State Agency appeals of Medicare coverage denials for beneficiaries dually eligible for Medicare and Medicaid; (2) the fee-for-service Recovery Audit (RA) program (also known as the Recovery Audit Contractor (RAC) program); and (3) other efforts by CMS to enhance its monitoring of payment accuracy under Medicare Parts A and B, which contributed to more denials of claims.

OMHA has implemented measures to try and address the increase in workload, including prioritizing the small numbers of beneficiary-initiated appeals and deferring assignment of new requests for hearings until an ALJ becomes available. In addition, OMHA has hosted two Medicare Appellant Forums to update stakeholders on the status of OMHA’s efforts to deal with the backlog. OMHA has implemented two pilot programs: (1) settlement conference facilitation, under which an independent OMHA facilitator meets with appellants and CMS to discuss the settlement of claims; and (2) a statistical sampling initiative, to provide appellants with an option to address large volumes of claim disputes.

OMHA is soliciting input on the current initiatives as well as suggestions for other activities that would address the Medicare claim and entitlement appeals workload and the backlog at OMHA. Specifically, OMHA requested feedback in response to the following questions:

  • Are there suggestions related to the current initiatives for addressing the increased workload and/or backlog of appeals at the Administrative Law Judge level that comply with current statutory authorities and requirements?
  • Are there other suggestions for addressing the increased workload and/or backlog of appeals at the Administrative Law Judge level that comply with current statutory authorities and requirements?
  • Are there any current regulations that apply to the Administrative Law Judge level of the Medicare claim and entitlement appeals process that could be revised to streamline the adjudication process while ensuring that parties to the appeals, as defined at 42 CFR §§ 405.902 and 405.906, are afforded opportunities to participate in the process and are kept apprised of appeals related to claims submitted by them or on their behalf?

Additional information about OMHA is available here.