On February 12, the U.S. Department of Health & Human 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 third level of the Medicare claim appeals process. At the forum, OMHA Director, Program Evaluation and Policy Division, Jason Green presented two alternative adjudication models: mediation of claims and statistical sampling. To this end, OMHA recently announced that it has implemented the two models: a mediation initiative, called the Settlement Conference Facilitation program, and the Statistical Sampling Initiative.
The Settlement Conference Facilitation is a pilot program of an alternative dispute resolution process that uses mediation principles to bring the appellant (the Medicare supplier or provider) and the Centers for Medicare & Medicaid Services (CMS) together to discuss the potential of a mutually agreeable resolution for claims appealed to the ALJ hearing level. If a resolution is reached, a settlement document will be drafted by the settlement conference facilitator to reflect the agreement, which includes dismissal of the ALJ hearing request, and the document will be signed by the appellant and CMS at the settlement conference session. The facilitator does not make official determinations on the merits of the claims at issue and does not serve as a fact finder, but may help the appellant and CMS see the relative strengths and weaknesses of their positions. The settlement conference facilitator is an OMHA employee; OMHA is a component of the U.S. Department of Health and Human Services (HHS) Office of the Secretary, and is organizationally and functionally separate from CMS.
The Statistical Sampling Initiative pilot program is designed to provide appellants with an option for addressing large volumes of claim disputes at the ALJ hearing level. Statistical sampling draws a random sample from all of the supplier’s claim denials and extrapolates, or projects, the results of the sample to all the claims. OMHA statistical sampling is conducted using a trained and experienced statistical expert to develop the appropriate sampling methodology in accordance with Medicare guidance, and to randomly select the sample units. An ALJ then reviews the sample units and makes findings and a decision about those sample units.
During the pilot, statistical sampling conducted at OMHA may be initiated by an appellant request or in response to an OMHA offer. An OMHA statistical sampling coordinator will serve as the central point of contact with an appellant in securing the initial consent for statistical sampling, and ensure that sampling efforts are coordinated throughout OMHA. A prehearing conference will be conducted by an ALJ to confirm consent for statistical sampling and address other matters to facilitate the hearing. After the prehearing conference order is issued and becomes binding, all appeals will be combined into a single appeal and assigned to a new ALJ for a hearing on the sample units selected by the OMHA statistical expert (unless all of the appeals were originally assigned to a single ALJ and that ALJ conducted the prehearing conference). After a hearing is conducted, the decision on the sample units will be extrapolated by a CMS contractor and applied to all of the supplier’s denied claims based on the projected amount.
For additional information, including program eligibility, visit OMHA’s Settlement Conference Facilitation program and the Statistical Sampling Initiative webpages.
