Not surprisingly to any agencies involved in the TPL project, a new report from the Office of Inspector General of the US Dept. of Health & Human Services found a range in inconsistencies and shortcomings in the Administrative Law Judge level of the Medicare appeal process.
A sampling of some of the findings of the study:
- Two State Medicaid agencies [one of which clearly is Massachusetts] filed more than 500 appeals each in 2010. Many ALJ staff raised concerns about these frequent filers, noting that some of these appellants appeal every payment denial, and pointing out that these appellants have an incentive to appeal because the cost is minimal and a favorable decision is likely
- The fully favorable [ALJ coverage decision] rate varied substantially by appellant type. For providers, it was 61 percent. In contrast, the fully favorable rate was just 22 percent for State Medicaid agencies.
- ALJs tended to interpret Medicare policies less strictly than QICs
- The favorable rate varied widely by ALJ. According to many ALJ staff, different philosophies among ALJs contribute to the variation in fully favorable rates. They said that given the same facts and the same applicable Medicare policy, some ALJs would make decisions that are favorable to appellants, while others would not.
The report’s recommendations to CMS and the Office of Medicare Hearings and Appeals include:
- Develop and Provide Coordinated Training on Medicare Policies to
- ALJs and QICs
- Identify and Clarify Medicare Policies That Are Unclear and
- Interpreted Differently
- Standardize Case Files and Make Them Electronic
- Revise Regulations To Provide More Guidance to ALJs Regarding
- the Acceptance of New Evidence
- Improve the Handling of Appeals From Appellants Who Are Also
- Under Fraud Investigation and Seek Statutory Authority To Postpone
- These Appeals When Necessary
- Seek Statutory Authority To Establish a Filing Fee
- Implement a Quality Assurance Process To Review ALJ Decisions
- Determine Whether Specialization Among ALJs Would Improve Efficiency.
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