Kusserow’s Corner: Office of Hearing Appeals Announces Huge Backlogs and Delays on Claims Appeals

The HHS Office of Medicare Hearings and Appeals (OMHA) announced “we anticipate that assignment of your request for hearing to an Administrative Law Judge may be delayed for up to 28 months.” This year an estimated 350,000 requests for ALJ review involving almost 595,000 claims will be received. The 63 ALJs are expected to decide on over 100,000 appeals involving about a quarter million claims. This is over 150% increase of the number of requests for ALJ reviews in 2012, involving about twice the number of claims, however the number of ALJs during this period will not increase. The result of all this is that an overwhelming number of appeals being filed and pending at OMHA will inevitably result in delays. The major backlog problem began and has been increasing since Congress in 2000 changed dramatically the process for Medicare claims denials and established five levels of review. This was followed in 2005 with reforms that created OMHA in HHS to be responsible for handling all “Level 3” appeals of Medicare claims denials. From the dates of these reforms and changes, the number of appeals escalated, but the resources available for the adjudicative process did not keep pace, leading the rapid increase of the backlog.

Tom Herrmann, who served for six years as an Appellate Judge for the HHS Medicare Appeals Council, stated recently that in the face of this rising backlog a provider can help expedite its claims appeal and improve its chances for a better appeal decision by following a variety of practices, techniques, and methods. Also, there are many things that should be avoided that will work against a provider’s best interest, such as losing an appeal by failing to properly organize and present evidence at the QIC level of review, making it easier for the ALJ to rule against claimants. He also stresses the importance of the manner and submission of a properly prepared “ALJ Appeal Memorandum” or “Prehearing Brief” to the ALJ prior to the scheduled hearing. Proper presentation at this level can be critical to the outcome, but many such presentations historically have fallen very short of what is needed. He notes further that many claimants fail to ensure all legal authority, evidence, technical issues to be decided are properly presented to the ALJ in form, format and content. In short, too much or too little in the presentation can delay or damage an appeal.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2013 Strategic Management Services, LLC. Published with permission.