On October 29, 2014, the Office of Medicare Hearings and Appeals (“OMHA“) hosted its second Medicare Appellant Forum (“Forum“) to address the status of the Medicare appeals backlog and related processing delays of Administrative Law Judge (“ALJ“) appeals, which are the third level of the Medicare appeals process that is available to suppliers, providers, and Medicare beneficiaries to challenge denied claims. Last week’s Forum was a follow-up to OMHA’s February 2014 Appellant Forum, which offered few assurances to stakeholders at the time that any effective remedies to the delays in the appeals process would have a meaningful impact in the near term. Much like OMHA’s February Forum, last week’s Forum provided an opportunity for OMHA to share with stakeholders an update regarding the actions that OMHA is taking to reduce the Medicare appeals backlog and the actions that OMHA plans to take going forward.
OMHA’s Chief ALJ, Nancy Griswold, and her colleagues described several meaningful steps forward that have occurred since February’s Forum. These developments include the February 2014 opening of OMHA’s fifth field office (adding additional ALJ capacity to handle pending cases), several key information technology and infrastructure initiatives that have been focused on improving and upgrading OMHA’s case intake and adjudication capabilities, and updates regarding the July 2014 launch of two pilot projects—the first involves statistical sampling, which OMHA says will provide appellants with an option for addressing large volumes of claims disputes at the ALJ level, and the second involves settlement conference facilitation, to try and bring appellants and Centers for Medicare & Medicaid representatives together in an alternative dispute resolution format to discuss the possibility of a mutually agreeable resolution to the appellant’s claims appealed to the ALJ hearing level.
Stakeholders across the board – providers, suppliers, and Medicare beneficiaries – take note! Earlier this week, OMHA released a Request for Information (OMHA-1401-NC) “soliciting suggestions for addressing the substantial growth in the number of requests for hearing filed with [OMHA], and backlog of pending cases.” This notice was subsequently published in the Federal Register on November 5, 2014. Comments are due to OMHA no later than 5 PM (EST) on December 5, 2014. Based on the specific questions posed in the notice, OMHA may be acknowledging the possibility that thinking outside the box is needed in order to deal effectively with the current Medicare appeals backlog and to find the best possible path forward.
Until there is a comprehensive statutory or regulatory solution to the Medicare appeals backlog, interested parties should keep abreast of OMHA’s activities and how they may affect your organization’s legal strategies and business decisions involving Medicare participation, coverage, and reimbursement. You can read more about last week’s Forum here. Also, consider submitting comments to show OMHA that solutions may exist that the agency has not otherwise thought of. Epstein Becker Green is available to assist with the drafting and submission of comments to OMHA as well as developing a strategy for undertaking a Medicare appeal.