The DHHS Office of Medicare Hearings and Appeals (OMHA) held its second appellant forum on Wednesday, October 29, 2014, in Washington D.C., to update the appellant community on OMHA's progress in addressing the massive appeals backlog that has accrued over the past two years and its progress with implementing the initiatives announced at its first Appellant Forum in February of this year. 

Status Update

The day began with comments from Chief ALJ Judge Nancy Griswold, the director of OMHA, related to OMHA's workload and the Medicare claims appeals backlog.  Of note in Judge Griswold's comments was that OMHA received a budget increase for FY 2014, allowing it to open a new Kansas City field office complete with 7 new ALJ teams and one associate chief ALJ, for a total adjudicative capacity of 8 new ALJs.  If the President's budget for FY 2015 is approved in full, OMHA will be able to add an additional 10 ALJ teams to the new Kansas City field office giving it greater flexibility in scheduling for cases in the Central and Mountain time zones.  In addition, OMHA used the increased appropriation expand its support staff in its central docketing office.  OMHA has also begun a field office redesign project which will allow it to decrease its space rental and free up funding to expand operations. 

According to Judge Griswold, OMHA began assigning cases to ALJs from its deferred docket starting on February 3, 2014; to date, OMHA has assigned 34,121 cases from its deferred pool and is currently assigning cases filed in the third quarter of FY 2013.  Beneficiary-filed appeals and expedited Part D appeals are averaging 109.3 day and 10 day processing times, respectively.  All other appeals have an Average Processing Time, the length of time from receipt of the request for hearing to the time an ALJ issues its decision, of roughly 414.8 days; this delay is expected to increase for the foreseeable future.  Over 50% of the appealed claims are related to RAC reviews, but there are a growing number of claims arising out of state agency audits.

OMHA Initiatives to Address Backlog

Judge Griswold also gave an overview of current OMHA initiatives, stressing that it is taking a "holistic" approach utilizing multi-level initiatives working hand in hand to address OMHA's workload and the appeals backload, rather than focusing on a single solution.  She broke the initiatives into several categories, outlined as follows:

  • Programmatic Initiatives
    • Standardizing business process
    • Use of statistical sampling (with appellant consent)
    • Alternative Dispute Resolution
      • e.g., Settlement Conference Facilitation Pilot
  • Information Technology
    • ALJ Appeals Status Information Systems website (AASIS)
    • Electronic Case Adjudication and Processing Environment (ECAPE)
    • Contract Scanning

In February, OMHA announced that it projected having the AASIS website, which will allow appellants to access basic appeal information including the date the appeal was received, appeal status, field office and ALJ assignment, and team phone numbers, operational by Summer 2014.  However, due to "programmatic delays" OMHA now projects that AASIS will be deployed by the end of this calendar year.  OMHA also revised its timeline regarding the more comprehensive case management website, ECAPE.  Originally estimated for Summer 2014, OMHA now projects awarding the development contract for ECAPE, which will allow case intake and assignment, workflow management, electronic filing and exhibiting, scheduling, decision writing and closing, management information, and a shared system of record, in January 2015, with a phase I release planned in October 2015 and a phase II release planned in September 2016. Finally, to manage pending appeals, Judge Griswold announced that OMHA has undertaken an initiative to scan into electronic format the unassigned requests for hearing, along with all associated documents, that are pending assignment to an ALJ.  OHMA anticipates that the contract for this program will be awarded by the end of this calendar year.

Jason Green, Director for Program Evaluation and Policy Division at OMHA, discussed the OMHA initiatives to reduce the appeal backlogs, including the Settlement Conference Facilitation Project and the Statistical Sampling Program (you can read more about those programs in our previous bulletin on those projects here).  Mr. Green stated that there has been one settlement conference so far, which was not successful.  Additional changes to these pilot programs may be announced in January 2015.

CMS Initiatives

Arrah Tabe-Bedward, Director, Medicare Enrollment & Appeals Group of the Centers for Medicare and Medicaid Services, revealed other potential initiatives to reduce the appeal backlog, including a modification to one of the lower appeal levels, such as the MAC or the QIC, to allow appellant an opportunity to discuss their claims directly with an adjudicator.  This step would be an opportunity for appellants to provide additional information or documentation related to their claims.  This program will be initially limited to one (undisclosed) contractor.

DAB Also Experiencing Backlog

Costance Tobias, Chair, Departmental Appeals Board, also gave an update on the backlog at the DAB.  DAB reviews ahve increased by 43% since 2013; 33% of which relate to RAC reviews.  Escalations from OMHA have also increased from 7 in 2013 to 107 in 2014. 

The meeting concluded with a short question and answer session.  Judge Griswold's closing remarks promised to update the public again on the backlog in approximately 6 months.

More details on the Second Appellant Forum can be obtained through the OMHA website here.  Materials from the Forum presentations will be posted at that site soon.