On February 12, the U.S. Department of Health & Humans Services (HHS) Office of Medicare Hearings and Appeals (OMHA) held a public session to explain the situation surrounding its decision to suspend Medicare audit claim appeals assignments to Administrative Law Judges (ALJs). The American Orthotic & Prosthetic Association (AOPA) had two representatives at this meeting, who were among the 350 in-person attendees, and reported on the proceedings. OMHA also posted the forum presentations to its website, www.hhs.gov/omha
According to AOPA, Chief ALJ Nancy Griswold underscored that OMHA has begun to resume assigning a limited number of backlogged cases to some ALJs, as their current backlog eases, and refused to characterize the deferral in the process of assigning cases as a freeze in ALJs hearing appeals. She cited data indicating that the ALJs are reviewing more than twice as many cases per day as they were a few years ago, and although 2013 receipts increase, OMHA resources remained relatively constant. She also told the audience that the 2014 fiscal year budget increased appropriations 18.6 percent over 2013 levels.
The second presentation at the forum was by Jason Green, director of OMHA’s Program Evaluation and Policy Division, which outlined several new long-term initiatives to increase efficiencies. These initiatives are mediation, attorney reviews, and statistical sampling. Interim IT improvement efforts include formation of an ALJ appeal status website and a Medicare appeals template system, and a pending long-term initiative is a system to electronically track the status of appeals.
AOPA went on to say that while the concerns and efforts expressed in the OMHA session are laudable, and that the outcry from the provider community has at least finally prompted HHS to move to reallocate some resources to improve ALJ timing, those resources are not enough to clear the backlog. “Some might question what incentives CMS/HHS have to rectify the backlog problems and restore a system of timely appeals-ones that meet the requirements of the federal law that your case be heard/decided within 90 days, a standard which is being breached every day,” AOPA said.
AOPA also discussed its concerns about the reported remedies: “[M]aking a fixed number of ALJs handle twice as many cases per day threatens the thoroughness of the appeal, and calls for mediation, attorney reviews, and statistical profiling all seem alarmingly geared toward changing measures of speed at the expense of the quality of the appeal, and that could all bode poorly for Medicare providers and the depth of examination and understanding the ALJs can exert on each case they decide. The longstanding ALJ system works, on those cases that are decided, albeit horribly delayed. AOPA fears that every ‘reform’ discussed at [the OMHA] session has some potential to make for less favorable results for provider success, alarming since this is really the only pathway providers have to seek fairness in a system of appeals and recoupments that is stacked against them.”