AOPA Attends OMHA’s 2nd Medicare Appellant Forum

AOPA’s Joe McTernan, Director of Coding and Reimbursement Services, Education and Programming, and Lauren Anderson, Manager of Communications, Policy, and Strategic Initiatives attended the Office of Medicare Hearings and Appeals (OMHA)’s second Appellant Forum on October 29th in Washington DC. The objectives of the forum were to provide updates on the status of OMHA operations, share information on their efforts to manage workload, and provide updates on departmental initiatives designed to address and reduce the backlog of ALJ hearing requests. OMHA hosted an initial appellant forum in February of this year after the memo announcing a suspension in assignment of new requests for Administrative Law Judge (ALJ) hearings, which was not expected to resume for two years. This forum had approximately 80 registrants in attendance, with another 500 attending via webinar.

Chief ALJ Judge Nancy Griswold provided an update on OMHA’s workload, which unsurprisingly, has not abated since the last forum. The OMHA office is receiving approximately 14,000 appeals per week, compared to the 1,250 per week in 2011 prior to the “Dear Physician” letter and subsequent increase in auditing activities. OMHA announced that the current processing time from receipt of request for hearing to the ALJ decision is currently 414.8 days, and is expected to increase as the number of hearing requests continue to increase. Beneficiary-initiated claims are still being expedited and face a much shorter wait time. Judge Griswold did announce that In February of this year, OMHA did start assigning cases again on a very limited basis.

A small comfort is that OMHA has received an 18.6% budget increase for 2014, and expects additional funding increases in the 2015 federal budget. With the increase, they have been able to open a new field office in Kansas City with 7 new ALJ teams, and expect to add 10 more teams in 2015.OMHA is also implementing some programmatic initiatives, including standardizing business practices, pilot programs for statistical sampling and mediation, IT initiatives including a portal to submit requests for hearings and checking status online. CMS also cited the prior authorization proposed rule that affects lower limb prosthetics and medical equipment as way to reduce appeals coming from CMS.

CMS’s recently appointed Patient Relations Coordinator Latesha Walker provided an update of CMS’s initiatives to reduce claims on their end. In her position, Ms. Walker aims to improve communications between providers and CMS stakeholders. She cited an example of a recent clarification regarding DMEPOS proof of delivery requirements issued to educate contractors, as a result of complaints from providers. There was a policy clarification that contractors should not deny claims because the delivery date was not filled in by the beneficiary, but auto-filled by providers. However, appeals resulting from previous denials over this issue remain in the queue for ALJ hearings.

The Medicare Appeals Council, which is a part of the Department Appeals Board, and provides final administrative review also has an increased workload, although their caseload is a fraction of OMHA’s. They currently have approximately 7400 appeals pending at the end of the 2014 fiscal year, compared to 1000 at the end of 2010. They are also implementing electronic records and expediting beneficiary initiated claims.

Audience questions and comments echoed the February forum, with appellants expressing dissatisfaction with the lower level processes, especially CMS’s RAC audit practices. Joe McTernan of AOPA reiterated the comments submitted by AOPA and members, that a final rule issued for prior authorization should include a guarantee of payment and no possibility of future audits on prior authorized claims.

While there is still no relief in sight, the forum concluded with an announcement that there will be another forum in six months to provide an update.