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Medicare Program; Appellant Forum Regarding the Administrative Law Judge Hearing Program for Medicare Claim Appeals

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Information about this document as published in the Federal Register.

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Office of Medicare Hearings and Appeals (OMHA), HHS.


Notice of Meeting.


This notice announces an Office of Medicare Hearings and Appeals (OMHA) Medicare Appellant Forum. The purpose of this event is to provide updates to OMHA appellants on the status of OMHA operations; to relay information on a number of OMHA initiatives designed to mitigate a growing backlog in the processing of Medicare appeals at the OMHA-level of the administrative appeals process; and provide information on measures that appellants can take to make the administrative appeals process work more efficiently at the OMHA-level.


Meeting Date: The OMHA Medicare Appellant Forum announced in this notice will be held on Wednesday, February 12, 2014. The OMHA Medicare Appellant Forum will begin at 10:00 a.m. Eastern Standard Time (e.s.t.) and check-in will begin at 9:00 a.m. e.s.t.

Deadline for Registration of Attendees and Requests for Special Accommodation: The deadline to register to attend the OMHA Medicare Appellants Forum and request a special accommodation, as provided for in the American's with Disabilities Act, is 5:00 Start Printed Page 394p.m., e.s.t. on Tuesday, January 28, 2014.


Meeting Location: The OMHA Medicare Appellants Forum will be held in the Cohen Auditorium of the Wilbur J. Cohen building located at 330 Independence Ave. SW., Washington, DC 20024.

We are exploring the feasibility of providing a toll-free phone line and/or live stream technology and/or webinar. Information on these options will be posted at a later date on the OMHA Web site;​omha/​index.html.

Registration and Special Accommodations: Individuals wishing to attend the OMHA Medicare Appellant Forum must register by following the on-line registration instructions located in section III. of this notice or by contacting staff listed in the FOR FURTHER INFORMATION CONTACT section of this notice. Individuals who need special accommodations should contact staff listed in the FOR FURTHER INFORMATION CONTACT section of this notice.

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Sylvia Baquero, (703) 235-0145,, or Paula Taylor, (703) 235-0125, Alternatively, you may forward your requests via email to; please indicate “Request for information” or “Request for special accommodation” in the subject line.

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I. Background

The Office of Medicare Hearings and Appeals (OMHA), a staff division within the Office of the Secretary of the U.S. Department of Health and Human Services (HHS), administers the nationwide Administrative Law Judge hearing program for Medicare claim and entitlement appeals under sections 1869(b)(1), 1155, 1876, 1852(g)(5), and 1860D-4(h) of the Social Security Act. OMHA ensures that Medicare beneficiaries and the providers and suppliers that furnish items or services to Medicare beneficiaries have a fair and impartial forum to address disagreements with Medicare coverage determinations made by Medicare contractors and determinations related to Medicare eligibility and entitlement, and income-related premium surcharges made by the Social Security Administration.

OMHA serves a broad sector of the public, including Medicare providers and suppliers, and Medicare beneficiaries, who are often elderly or disabled and among the nation's most vulnerable populations. OMHA administers its program in four field offices, including the Southern Field Office in Miami, Florida; the Midwestern Field Office in Cleveland, Ohio; the Western Field Office in Irvine, California; and the Mid-Atlantic Field Office in Arlington, Virginia. OMHA uses in-person, video-teleconferencing (VTC) and telephone conference formats to provide appellants with hearings.

OMHA was established in July 2005 pursuant to section 931 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173), which required the transfer of responsibility for the Administrative Law Judge hearing level of the Medicare claim and entitlement appeals process from the Social Security Administration to HHS. OMHA was expected to improve service to appellants and reduce the average 368-day time frame to receive a hearing decision that appellants experienced with the Social Security Administration, in accordance with 90-day adjudication time frame mandate required by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Pub. L. 106-554).

At the time of OMHA was established, it was envisioned that OMHA would receive the traditional claim and entitlement appeals workload from the Medicare Part A and Part B programs, and the Medicare Part C Medicare Advantage program; and a new workload of appeals from the Medicare Part D Prescription Drug program and the Income Related Monthly Adjustment Amount (IRMAA) premium surcharges assessed by the Social Security Administration. However, beginning in fiscal year 2010, new workloads including permanent establishment of the Recovery Audit (RA) program and termination of several demonstration projects involving Medicare State Agencies (MSA), have emerged that had not been built into the OMHA workload models. The steady growth in traditional Medicare appeals combined with these new workloads has strained OMHA's ability to meet the adjudication time frame mandate while maintaining quality.

As a result of the anticipated workload increase from the traditional appeals and the increased workload resulting from MSA appeals and the RA program, a backlog of appeals began to form in fiscal year 2012 in which more requests for hearing were being filed than could be adjudicated. In 2013, appealed claims related to the RA program grew to over 136,000, further exacerbating the backlog of cases and resulting in a substantial increase in the adjudication time frame.

As the unprecedented growth in claim appeals continues to exceed the available adjudication resources to address appeals, OMHA is taking measures to mitigate the workload increase and planning future activities to bring efficiencies to the appeals process at the OMHA-level. One of the immediate measures has been to ensure that the relatively small numbers of beneficiary-initiated appeals are being immediately addressed by prioritizing their cases. For the remaining cases, OMHA has suspended assignments of new requests for hearing until an adjudicator becomes available, which will allow cases to be assigned more efficiently on a first in/first out basis as an Administrative Law Judge's case docket is able to accommodate additional workload. In addition, OMHA is vigorously pursuing an electronic case adjudication processing environment (ECAPE) to bring new efficiencies and appellant-access to the OMHA-level of the appeals process.

The OMHA Medicare Appellant Forum will address these initiatives, as well as potential future initiatives, and will solicit input from the appellant community to help OMHA evaluate its policies and procedures to achieve meaningful backlog reduction strategies and process efficiencies while remaining compliant with applicable legal authorities.

II. Medicare Claim Appeal Appellant Forum and Conference Calling/Webinar Information

A. Format of the OMHA Medicare Appellant Forum

As noted in section I. of this notice, OMHA is conducting this outreach to appellants of the Medicare claim appeals process to provide updates on initiatives to mitigate a growing backlog in the processing Medicare appeals at the OMHA-level, and to solicit input to achieve meaningful backlog reduction strategies and process efficiencies. Information regarding the OMHA Medicare Appellant Forum can be found on the OMHA Web site at:​omha/​index.html.

The majority of the forum will be reserved for presentations of workload data, processes and policy discussions, and recommendations from agency presenters. The time for each presentation will be approximately 30 to 60 minutes and will be based on the material being addressed in the presentation.

Questions and comments from in-person attendees will be solicited at the Start Printed Page 395end of each planned presentation and during a separate question and answer session as time permits. In addition, questions related to the OMHA-level of the Medicare claim appeals process will also be accepted on the attendee registration, for potential response during the appropriate presentation.

B. Conference Call, Live Streaming, and Webinar Information

For participants who cannot attend the OMHA Medicare Appellant Forum in person, there may be an option to view and participate in the OMHA Medicare Appellant Forum via live streaming technology and/or a webinar. Information on the whether these capabilities will be available as part of this forum will be posted on the OMHA Web site at:​omha/​index.html. Please continue to check the Web site for updates on this upcoming event.

Disclaimer: We cannot guarantee reliability for live streaming technology and/or a webinar.

III. Registration Instructions

The OMHA Executive Office is coordinating attendee registration for the OMHA Medicare Appellant Forum. While there is no registration fee, individuals planning to attend the forum must register to attend. In-person participation is limited to two (2) representatives from each organization. Additional individuals can participate by telephone conference or webinar if these services are made available. Information on participation by telephone conference or webinar will be posted on the OMHA Web site at:​omha/​index.html. Registration may be completed online at the following web address:​omha/​index.html. Seating capacity for in-person attendees is limited to the first 400 registrants.

After completing the registration, online registrants will receive a confirmation email which they should bring with them to the meeting(s). If you are unable to register online, you may register by sending an email to Please include your first and last name, title, organization, address, office telephone number, and email address. If seating capacity has been reached, you will be notified that the meeting has reached capacity.

IV. Security, Building, and Parking Guidelines

Because the OMHA Medicare Appellant Forum will be conducted on Federal property, for security reasons, any persons wishing to attend these meetings must register by the date specified in the DATES section of this notice. Please allow sufficient time to go through the security checkpoints. It is suggested that you arrive at the Wilbur J. Cohen building, located at 330 Independence Ave. SW., Washington, DC 20024, no later than 9:30 a.m. e.s.t. if you are attending the forum in person so that you will be able to arrive promptly for the meeting.

Security measures include the following:

  • Presentation of photographic identification to the Federal Protective Service or Guard Service personnel.
  • Passing through a metal detector and inspection of items brought into the building. We note that all items brought to the Cohen Building, whether personal or for the purpose of demonstration or to support a demonstration, are subject to inspection. We cannot assume responsibility for coordinating the receipt, transfer, transport, storage, set-up, safety, or timely arrival of any personal belongings or items used for demonstration or to support a demonstration.


Individuals who are not registered in advance will not be permitted to enter the building and will be unable to attend the forum in person. The public may not enter the building earlier than 45 minutes prior to the convening of the forum.

Attendees must enter the Cohen Building thru the C-Street entrance and proceed to the registration desk. All visitors must be escorted in areas other than the auditorium area and access to the rest rooms on the same level in the building. Seating capacity is limited to the first 400 registrants.

Parking in Federal buildings is not available for this event. In addition, street side and commercial parking is extremely limited in the downtown area. Attendees are advised to use Metro-rail to either the Federal Center SW station (Blue/Orange line) or the L'Enfant Plaza station (Yellow/Green or Blue/Orange lines). The Wilbur J. Cohen building is approximately 11/2 blocks from each of these Metro-rail stops.

(Catalog of Federal Domestic Assistance Program No. 93.770, Medicare—Prescription Drug Coverage; Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program)

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Dated: December 24, 2013.

Nancy J. Griswold,

Chief Administrative Law Judge, Office of Medicare Hearings and Appeals.

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[FR Doc. 2013-31461 Filed 1-2-14; 8:45 am]