Kusserow’s Corner: OMHA Medicare Appeals Update

In previous blog articles, I reported on great backlog problems with the Office of Medicare Hearings and Appeals (OMHA). Nancy Griswold, Chief Administrative Law Judge (ALJ), announced that “due to the rapid and overwhelming increase in claims appeals, effective July 15, 2013, OMHA temporarily suspended the assignment of most new requests for an Administrative Law Judge hearing.” This suspension is anticipated to remain in effect for at least two years, in order to allow OMHA to catch up on almost 375,000 claims already backlogged in its docketing system. OMHA then announced it would be hosting a Forum on Medicare Appeals on February 12, 2014. The Forum opened with the stated objectives to provide an update on OMHA operations, explain initiatives to mitigate the growing backlog of cases, provide information on how providers can assist in making the process more efficient, and provide answers to appellant questions. It is important to note that there are a variety of appeals handled by OMHA, including;

  1. Medicare eligibility and entitlement
  2. Part B and D income-related premiums
  3. Part A and B pre- and post-payment claims (MACs, RACs, PSC/ZPICs)
  4. Continuation of care (QIOs)
  5. Part C managed care coverage (Medicare Advantage programs)
  6. Part D prescription drug coverage (Prescription Drug Plans)

OMHA reported that its workload has been skyrocketing over the last several years, growing now at a rate of 40 percent per year. It now stands at 437,000 cases. OMHA has been steadily and increasingly falling behind in the adjudication process to where, in 2013, there were about 350,000 cases received, and the approximately 65 ALJs were only able to adjudicate 79,000. This is in addition to the carryover from prior periods. This led to the decision to have a moratorium on assigning new cases until the backlog could be addressed.

All of this means that there is a clear need for a more effective case management system including:

  • Providing electronic messaging to appellants on regarding case status and proceedings
  • Identifying and flagging potentially duplicate appeals
  • Acknowledging receipt of appeals
  • Making appeals more accessible via electronic filing
  • Allowing electronic submission of evidence to support appeals, including the viewing of documents already in an appeals file
  • Ensuring integration of claims data with the MACs and QICs to support files necessary for appeals
  • Responding to questions
  • Supporting the transmission of information electronically during the closing process

At the Forum, OMHA provided an update that included the following:

  1. CMS has started to aid the sharing of information regarding cases and appeals.
  2. OMHA is expediting hearings for beneficiary appeals.
  3. OHMA is seeking to develop a balance between an expeditious appeals process and quality of decisions and a measure of consistency of decisions across ALJs.
  4. Confronting the issue that the appeals process was premised on a 90-day turnaround of appeals and OMHA is incapable of meeting this deadline.

OMHA has been working on developing an appeals status website, referred to as the ALJ Appeals Status Information System (AASIS), to communicate to appellants the status of level 2 and 3 appeals. It is expected to become operational in spring 2014. It will track the status of the case in terms of assignment and other relevant information including responsible contacts. This system should help streamline and make the process more efficient once appeals have been docketed.

An interim initiative also underway is the Medicare Appeals Template System (MATS), as part of the document management process. It provides templates for forms and needed data that can be used to manage better the information received. It also sets the stage for long-term improvements. It is currently being piloted in the Miami office and will go nationwide in the second quarter of 2014. OMHA is also working on a long term IT initiative referred to as Electronic Claims Adjudication and Processing Environment (ECAPE) whose major functions include:

  • Case intake
  • Assignment
  • Workflow management
  • Exhibiting
  • Decision writing
  • Closing
  • Management Information (statistics, metrics, etc.)
  • Shared system of record

The long-term ECAPE solution will be contracted out with RFPs in Winter/Spring 2014 with contract award coming in the summer of 2014.

Tom Herrmann, retired Appellate Judge on the Medicare Appeals Council, noted that OMHA’s “stakeholder” meeting is virtually unprecedented. “In my over thirty years with the Federal Government I have never observed a situation where a Governmental entity was willing to be so transparent about its operational problems and willing to share information with the public.” “While extensive delays in receiving ALJ review of an appeal will continue, OMHA shared with forum participants suggestions for expediting the appeals process through adherence to procedural requirements and submission of prehearing documents to an ALJ.”

While the forum was organized by OMHA, participants overwhelmingly commented that the fundamental problems with the Medicare appeals process are at the initial and redetermination levels, which are handled by Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs). The staff at CMS was asked to be more vigilent in overseeing the contractor processing of appeals. Added responsiveness by the MACs would lessen the number of appeals that get elevated to the ALJ level of review.


Recent blogs on the subject:





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 © 2014 Strategic Management Services, LLC. Published with permission.