Office Of Medicare Hearings And Appeals - HHS.gov
Office of Medicare Hearings and AppealsDEPARTMENTof HEALTHand HUMANSERVICESFiscal Year2017Office of MedicareHearings and AppealsJustification ofEstimates forAppropriations CommitteePage 1
Office of Medicare Hearings and AppealsDEPARTMENT OF HEALTH AND HUMAN SERVICESOffice of the SecretaryOffice of Medicare Hearings and AppealsOffice of the Chief Judge5201 Leesburg Pike, Suite 1800Falls Church, VA 22041I am pleased to present the Office of Medicare Hearings and Appeals (OMHA) Fiscal Year 2017Congressional Justification. This budget request reflects OMHA’s strong commitment to providing anindependent forum for the fair and efficient adjudication of Medicare appeals for beneficiaries andother parties.Since beginning operations in July 2005, OMHA has been committed to continuous improvement in theMedicare appeals process through responsible stewardship despite significant increases in workload.This commitment continues to inspire OMHA’s strategic plan. Given current resources and averagereceipt levels, OMHA is receiving more than one year’s worth of work every nineteen weeks. With thesereceipt levels far exceeding the adjudication capacity of its 77 Administrative Law Judges (ALJ), OMHA isunable to issue Medicare decisions in 90 days as envisioned by statute.The FY 2017 budget reflects OMHA’s efforts to not only build upon the operational success achievedduring its first eleven years, but to implement its multi-year strategy to balance resources withworkloads and eliminate the backlog. The first of these is an Adjudication Expansion Initiative torespond to the agency’s foremost challenge: the resulting backlog of appeals. OMHA has also taken anumber of administrative actions to reduce the pending appeals workload such as settlementconference facilitations which offer alternative dispute resolution as an option for resolution of pendingappeals. In addition, proposed legislative changes such as the Medicare Magistrate Program will helpadjudicate more appeals at a lower cost.Although OMHA recognizes that the improvements to the appeals process envisioned by administrativeactions and proposed legislation must be a part of the solution, these changes alone will not enableOMHA to adjudicate the significant number of appeals already pending at OMHA or those which OMHAprojects will be received in the coming years. Although the budget increase in FY 2016 allowed OMHAto add 15 additional ALJ teams, this number does not position the Agency to handle its current receiptlevels or begin to reduce the pending backlog of appeals. In order to avoid collapse of the system, asignificant funding increase is required. The FY 2017 budget request builds upon the FY 2016 increaseand must serve as a baseline for future requests.Above all, this FY 2017 budget reflects OMHA’s efforts to focus on the agency’s mission, by increasingefficiency and capacity by further enhancing service to the public.Sincerely,Nancy J. GriswoldChief Administrative Law JudgePage 2
Office of Medicare Hearings and AppealsTable of ContentsOrganizational Chart . 4Organization Chart: Text Version . 5Introduction and Mission . 6Overview of Budget Request . 7Overview of Performance . 8All Purpose Table. 10Appropriations Language . 10Amounts Available for Obligation . 10Summary of Changes . 11Budget Authority by Activity - Direct . 12Authorizing Legislation . 12Appropriation History Table. 13Narrative by Activity. 14FY 2017 Budget Request . 15Outputs and Outcomes Table . 17FY 2017 Budget by HHS Strategic Objective . 18Budget Authority by Object Class . 19Salaries and Expenses . 20Detail of Full Time Equivalents . 21Detail of Positions . 22Page 3
Office of Medicare Hearings and AppealsOrganizational ChartOffice of Medicare Hearings and AppealsCHIEF ADMINISTRATIVE LAW JUDGENancy GriswoldOffice of ManagementOffice of Program Integrity and EthicsDIRECTOREileen McDanielDIRECTORKaren AmesDEPUTY CHIEF ADMINISTRATIVE LAW JUDGEC.F. MooreArlingtonField OfficeClevelandField OfficeIrvineField OfficeKansas CityField OfficeMiamiField OfficeASSOCIATECHIEFADMINISTRATIVELAW JUDGEWilliam FarleyASSOCIATECHIEFADMINISTRATIVELAW JUDGEChristian KnappASSOCIATECHIEFADMINISTRATIVELAW JUDGEStuart WeinASSOCIATECHIEFADMINISTRATIVELAW JUDGEDavid KraneASSOCIATECHIEFADMINISTRATIVELAW JUDGEBrian HaringHEARING OFFICEDIRECTORJim RiceHEARING OFFICEDIRECTORSteven YelenicHEARING OFFICEDIRECTORAndreas FrankHEARING OFFICEDIRECTORVicki PollockHEARING OFFICEDIRECTORElizabeth Nodal.Page 4
Office of Medicare Hearings and AppealsOrganization Chart: Text VersionOffice of Medicare Hearings and Appeals Chief Administrative Law Judge, Nancy Griswold Deputy Chief Administrative Law Judge, C.F. MooreThe following offices report directly to the Chief Administrative Law Judge: Director, Office of Managemento Director, Office of Program Integrity and Ethicso Eileen McDanielKaren AmesArlington Field OfficeoAssociate Chief Administrative Law Judge, William FarleyoHearing Office Director, Jim RiceCleveland Field OfficeoAssociate Chief Administrative Law Judge, Christian KnappoHearing Office Director, Steven YelenicIrvine Field OfficeoAssociate Chief Administrative Law Judge, Stuart WeinoHearing Office Director, Andreas FrankKansas City Field OfficeoAssociate Chief Administrative Law Judge, David KraneoHearing Office Director, Vicki PollockMiami Field OfficeoAssociate Chief Administrative Law Judge, Brian HaringoHearing Office Director, Elizabeth NodalPage 5
Office of Medicare Hearings and AppealsIntroduction and MissionThe Office of Medicare Hearings and Appeals (OMHA), an agency of the U.S. Department of Health andHuman Services (HHS), administers hearings and appeals nationwide for the Medicare program. OMHAensures that Medicare beneficiaries, providers and suppliers have access to an independent forum andopportunity for a hearing conducted pursuant to the Administrative Procedures Act on disputedMedicare claims. By providing a timely and impartial review of Medicare appeals, OMHA encouragesproviders and suppliers to continue to provide services and supplies to Medicare beneficiaries. Suchaccess to timely adjudication of disputes is essential to the integrity of the Medicare system. On behalfof the Secretary of HHS, the Administrative Law Judges (ALJs) within OMHA conduct impartial hearingsand issue decisions on claims determinations appeals involving Medicare Parts A, B, C, D, as well asMedicare entitlement and eligibility appeals.MissionOMHA is a responsible forum for fair, credible and timely decision-making through an accomplished,innovative and resilient workforce. Each employee makes a difference by contributing to shapingAmerican health care.VisionWorld class adjudication for the public good.Statutory Decisional TimeframeThe Benefits Improvement and Protection Act of 2000 envisions that OMHA will issue decisions ondisputed claims within 90 days after a request for hearing is filed.Page 6
Office of Medicare Hearings and AppealsOverview of Budget RequestThe FY 2017 request for OMHA of 250,000,000 represents a 142,619,000 million increase over FY2016. The request includes 120,000,000 in budget authority and 130,000,000 in program levelfunding from pending legislation to address the backlog of Medicare appeals. HHS estimates thatenactment of the legislation would provide an additional 125 million in Recovery Audit (RA)Collections, and an estimated 5 million from a proposed filing fee. Overall, OMHA’s budget requestmakes investments to support HHS Strategic Goals to Strengthen Healthcare and Ensure Efficiency,Transparency, Accountability and Effectiveness of HHS Programs. This will be accomplished bymaximizing its organizational adjudicatory capacity to meet the needs of the public (i.e. Medicarebeneficiaries, who are among our nation’s most vulnerable populations, providers, suppliers and thetax-paying public).The request positions OMHA to hear more Medicare appeals than ever before by expanding theagency’s capacity from the projected 92 ALJ teams on-board by the end of FY 2016 to 193 ALJ teamsnationwide by the end of FY 2017 including establishing five new field offices. After gaining 6 to 12months of experience, these new ALJ teams will collectively adjudicate approximately 101,000additional appeals annually. The additional funding also supports a Medicare Magistrate programproposed in the FY 2016 budget request which would address less complex cases. This alternateadjudication method will further increase OMHA’s appeals resolution capacity at a significantly lowercost per appeal than the existing ALJ hearing process. The FY 2017 request will increase OMHA’sadjudication capacity and provide for expanded administrative efficiencies which aim to mitigate theMedicare appeals backlog.Page 7
Office of Medicare Hearings and AppealsOverview of PerformanceOMHA has remained committed to continuous improvement in the Medicare appeals process byimplementing initiatives to enhance the quality and timeliness of its services. However, as workloadshave grown dramatically, it has become impossible for the agency to achieve its goals. From FY 2009 toFY 2014, OMHA experienced an overall 1,222% increase in the number of appeals received annually,with the most dramatic growth in appeals workload occurring in the three-year period from FY 2011through FY 2013. During these three years alone, workload grew by an unprecedented 545% (60,000appeals in FY 2011 and 384,000 appeals in FY 2013). This dramatic increase in both Recovery Audit (RA)and non-RA appeals has had a predictably detrimental impact on the agency’s performance. With theexception of beneficiary appeals, which are prioritized, OMHA has not been able to issue decisions in 90days for the past five years. In FY 2015, OMHA adjudicated only 9.3% of its BIPA claims in 90 days, farshort of the 15% performance target. In addition, the average processing time on closed workload in FY2015 was 661 days. The average age of pending appeals at OMHA has risen at an even more alarmingrate and measures nearly 800 days as of November 2015, indicating that processing times will continueto increase until the backlog of pending appeals has been resolved.Through increased process efficiency and targeted addition of support staff, OMHA has streamlined thebusiness process and has implemented a number of new initiatives to the maximum extent possiblewithout sacrificing program integrity. Adjudication teams have more than doubled their productivitysince 2009, with productivity hovering around the maximum sustainable levels of approximately 1,000appeals per team annually. The only viable way for OMHA to fully address the receipt level and improveperformance is to systematically add adjudicators over the next few years while concurrentlyimplementing other short and long-term departmental and OMHA policy initiatives. Agencyperformance (ability to process BIPA cases within 90 days) will remain quite low until the backlog is fullyresolved and OMHA is once again able to process appeals as they are received.Although adjudication delays at OMHA have impacted all categories of appellants, OMHA is able tocontinue its support of the HHS objective to “Leave the Department Stronger” through the prioritizationof beneficiary appeals which comprise its most vulnerable stakeholders. The average wait time todisposition for prioritized beneficiary appeals has decreased from 244 days in FY 2013 to 78 days forappeals filed in FY 2015.Despite the sharp workload increase, OMHA also continues its unwavering support of the HHS StrategicGoal 4 to Strengthen Program Integrity. OMHA continues to evaluate its customer service through anindependent evaluation that captures the scope of the Level III appeals experience by randomlysurveying selected appellants and appellant representatives. Measure 1.5 aims to ensure appellantsand related parties are satisfied with their Medicare appeals experience regardless of the outcome oftheir appeal. The measure is evaluated on a scale of 1 – 5, 1 representing the lowest score (verydissatisfied) and 5 representing the best score (very satisfied). In FY 2015, OMHA achieved a 3.9 level ofappellant satisfaction nationwide, exceeding the FY 2015 target of 3.4. However, if processing times areallowed to increase due to the pending workload, it is certain that appellant’s frustration with increasingprocessing times will grow and that their level of satisfaction with the process will decrease. In fact, theoverall level of appellant satisfaction has declined from a high of 4.3 recorded in FY 2010 prior to theformation of the backlog.In addition, OMHA’s Medicare Appellant Forum is a bi-annual event designed to inform and educate theappellant community on the challenges related to the appeals backlog, and measures it can undertakePage 8
Office of Medicare Hearings and Appealsto reduce inefficiencies in appeals processing. OMHA’s Appellant Forums have included speakers fromall levels of the appeals process and departmental leaders. A primary goal of this event has been to beas transparent as possible concerning the challenges faced by the appeals system and to keep appellantsinformed about current initiatives, pending pilots, demonstration projects and evolving plans designedto address the workload at all levels of appeal. OMHA held its first forum in February 2014, its second inOctober 2014 and its third in June 2015. The fourth forum will be held in the spring of 2016.Page 9
Office of Medicare Hearings and AppealsAll Purpose Table(Dollars in Thousands)Office of Medicare Hearingsand AppealsDiscretionary BudgetAuthorityRecovery Audit CollectionsRefundable Filing FeeTotal OMHAFTEFY 2015FinalFY 2016Enacted87,381107,381FY 642125,0005,000250,0001,308FY 2017 /FY 2016 125,000 5,000 142,619 666* 12,619*Includes 107 FTE for full year impact of FY 2016 hires and 559 FTE for FY 2017 hiresAuthorizing Legislation: . . . . Title III of the PHS ActFY 2017 Authorization . . . . . . . IndefiniteAllocation Method . . . .Direct FederalAppropriations LanguageFor expenses necessary for the Office of Medicare Hearings and Appeals, [ 107,381,000] 120,000,000,to be transferred in appropriate part from the Federal Hospital Trust Fund and the FederalSupplementary Medical Insurance Trust Fund.Amounts Available for ObligationDetailTrust Fund Discretionary AppropriationSubtotal, adjusted trust fund annualappropriationUnobligated balance lapsingTotal ObligationsFY 2015FinalFY 000FY 3887,218,462107,381,000120,000,000Page 10
Office of Medicare Hearings and AppealsSummary of ChangesBudget Year and Type of AuthorityDollarsFY 2016 EnactedFY 2017 President’s Budget AuthorityNet Change107,381120,000 12,619IncreasesFY 2017FTEFull-time permanentOther personnel compensationCivilian personnel benefitsTravel and transportation of personsRental payments to GSACommunications, utilities, and misc. chargesPrinting and reproductionOther services from non-Federal sourcesOthers goods and services from FederalsourcesOperation and maintenance of equipmentSupplies and materialsTotal IncreasesDecreasesTotal IncreasesTotal DecreasesTotal Net ChangeFY 2017BudgetAuthority642749 FY 2017 /FY 2016FTE107--4,6641,217-FY 2017FTETransportation of thingsOperation and maintenance of facilitiesEquipmentTotal DecreasesTotal ChangesFTEFY 2017BudgetAuthority-FY 2017 FTE749749FY 2017 /FY 2016FTE310708578FY 2017BudgetAuthority120,000120,000-FY 2017 /FY 2016 FTE 107 107FY 2017 /FY 17,272FY 2017 /FY 2016BA4083,2321,0134,653FY 2017 /FY 2016 BA 12,619 12,619Page 11
Office of Medicare Hearings and AppealsBudget Authority by Activity - Direct(Dollars in Thousands)FY 2015FinalActivityFY 2017President’sBudgetFY 2016EnactedOffice of Medicare Hearings and Appeals (OMHA)OMHA FTE87,381526107,381642120,000749Total, Budget Authority87,381107,381120,000526642749Total, FTEAuthorizing Legislation(Dollars in Thousands)OMHAOffice of Medicare Hearings andAppeals, Social Security Act,Titles XVIII and XITotal AppropriationFY 2016AmountAuthorizedFY 2016AppropriationsActFY 2017AmountAuthorizedFY 2017President’sBudgetIndefinite 107,381Indefinite 120,000- 107,381- 120,000Page 12
Office of Medicare Hearings and AppealsAppropriation History TableDetails2008Trust Fund AppropriationRescissions (P.L. 110-161)Subtotal2009Trust Fund AppropriationSubtotal2010Trust Fund AppropriationSubtotal2011Trust Fund AppropriationRescissions (P.L. 112-10)Subtotal2012Trust Fund AppropriationRescissions (P.L. 112-74)Subtotal2013Trust Fund AppropriationRescissions (P.L. 113-6)Sequestration (P.L. 112-25)TransfersSubtotal2014Trust Fund AppropriationSubtotal2015Trust Fund AppropriationSubtotal2016Trust Fund AppropriationSubtotal2017Trust Fund AppropriationSubtotalBudgetEstimates ropriations65,000,000(1,136,000)63,864,00
The Office of Medicare Hearings and Appeals (OMHA), an agency of the U.S. Department of Health and Human Services (HHS), administers hearings and appeals nationwide for the Medicare program. OMHA ensures that Medicare beneficiaries, providers and suppliers have access to an independent forum and
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