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ALJ Backlog May Soon Be Alleviated by Statistical Sampling Pilot

On July 8, 2014, the Office of Medicare Hearings and Appeals (“OMHA”) posted to its website a new sampling pilot initiative to address large volumes of claims pending at the ALJ stage of appeal. The sampling request can be initiated by an appellant, or OMHA may offer an appellant the sampling pilot.

To be eligible for the statistical sampling pilot:
– A request for hearing must appeal a Medicare Qualified Independent Contractor (QIC) reconsideration decision.

– The appellant must be a single Medicare provider or supplier (if multiple providers or suppliers with multiple National Provider Identifiers (NPIs) are owned by a single entity, the owning entity may serve as “a single provider or supplier” provided that the owning entity agrees to accept any payment that may be due from Medicare as a single payment, or agrees to make any payment that may be due to Medicare as a single payment).

– All jurisdictional requirements for a hearing before an Administrative Law Judge must be met for the request for hearing and all appealed claims.

– The beneficiary must not have been found liable after the initial determination or participated in the QIC reconsideration.

– The claims must be currently assigned to one or more Administrative Law Judges or have been filed during the time period currently being assigned by OMHA Central Operations – at this time, that includes appeals that were filed between April 1, 2013, and June 30, 2013.

– No hearing on the claim has been scheduled or conducted.

– There must be a minimum of 250 claims and all claims must fall into only one of the following categories: (a) Pre-payment claim denials; (b) Post-payment overpayment non-Recovery Audit Contractor (“RAC”) claim denials; or (c) Post-payment (overpayment) RAC claim denials from one RAC.

– There cannot be an outstanding request for Settlement Conference Facilitation for the same claims.

Appellants who are eligible and interested in the pilot must complete a written request for sampling along with a detailed spreadsheet of claims for consideration. OMHA has included template request documents which can be accessed here.

Many hospitals may be interested in evaluating whether or not initiating the pilot will be beneficial. While this may expedite the adjudication of long-awaiting appeals, the downsides of this project should also be considered prior to making a final determination to seek entry into the pilot.

For more information or to discuss whether or not this initiative should be explored for your entity, please contact Abby Pendleton, Esq. (apendleton@thehlp.com or 248 996-8510) or Jessica L. Gustafson, Esq. (jgustafson@thehlp.com or 248 996-8510).

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