OMHA trying to speed claims appeals process

The Medicare appeals backlog, which at its pinnacle had more than 650,000 claims waiting for adjudication before an administrative law judge (ALJ), is shrinking, according to Office of Medicare Hearings and Appeals (OMHA) chief ALJ Nancy Griswold. Griswold told attendees at the Health Care Compliance Association’s (HCCA) Compliance Institute that OMHA is pursuing a number of initiatives to reduce the backlog and speed claim resolution. Joined by Andrew B. Wachler of Wachler & Associates, Griswold discussed policy and regulatory changes to the appeals process, and Wachler shared best practices.

OMHA is doing a demonstration project using voluntary formal telephone discussions with durable medical equipment (DME) suppliers in Medicare Administrative Contractor (MAC) Jurisdictions C & D. These discussions give the supplier an opportunity to present facts and additional documentation to support resolution of the appeal. According to Griswold, over 5,000 appeals have favorably resolved through the demonstration project, while more than 16,000 have been remanded to reopen or resolve the claim favorably. The agency is also working on settlement conference facilitation (resolving more than 10,000 appeals since June 2014), adjudication through statistical sampling, and use of a senior attorney on the record.

Griswold also discussed OMHA’s plans for the Electronic Case Adjudication Processing Environment (ECAPE). Release 1, which consists of a public portal for case intake and appellants, is scheduled for Spring 2017, with additional releases planned through Summer 2018.

Wachler explained that preparation is key for attorneys representing clients in appeals before OMHA, and explained that best practices include prominently listing the Medicare Appeal Number, ensuring that all information submitted is accurate and consistent, documenting proof of service, submitting only one request per Medicare Appeal Number, and keeping track of all due dates. He also recommended that attorneys wait until an ALJ is assigned to the case before attaching evidentiary submissions or additional filings; rather than submitting that information to OMHA Central Operations, Wachler says it can be directly submitted to the ALJ.

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  1. […] is looking at a number of ways to deal with the backlog; (see OMHA trying to speed claims appeals process, April 18, 2017). One solution is legislation. Speaking at the Health Care Compliance Association […]