ALJs to Transfer to HHS July 1

WASHINGTON–Home care providers will soon need to send appeals
of carrier fair hearing decisions to the Department of Health and
Human Services.

As mandated by the MMA and the Benefits Improvement and
Protection Act (BIPA) of 2000, the Administrative Law Judge
function, which covers appeals on carrier fair hearing decisions,
will move from Social Security jurisdiction to HHS’ Office of
Medicare Hearing and Appeals July 1. The new HHS ALJs will handle
carrier fair hearing decisions dated on or after June 30.

The change has caused some concern among providers. According to
some observers, ALJs, who handle second-level appeals, have
maintained impartiality because they work for the SSA, and moving
them to HHS control could create a conflict of interest.

“ALJs have been in many ways the saving grace for providers,”
according to Ann Howard, director of federal policy for the
American Association for Homecare. “Home care providers have a
remarkable rate of success before ALJs.”

She added that the association will monitor how HHS evaluates
the ALJs–and whether the appeal judges remain truly independent.
“Who’s going to evaluate them? How are they going to be evaluated,
and what are they going to evaluate them on?” she asked. “If they
don’t give proper deference to CMS policy, will they be sent to the
ALJ doghouse?”

The transfer is among the first steps in the government’s plan
to reform the Medicare claims appeals process. By the start of next
year, a new entity called Qualified Independent Contractors will
hear first-level appeals, replacing the current “fair hearing”
process now handled by the Medicare carriers. The QICs will include
review panels of medical professionals who will reconsider all
cases involving medical necessity issues. According to CMS, this
change should reduce the average time frames for fee-for-service
Medicare claims appeals from 1,000 to 300 days.

Those QICs, CMS said, should also alleviate concerns over
fairness during claims appeals. The QICs will offer “routine
considerations … of all medical necessity issues,” the agency
said in a rule proposed earlier this year. “As a result, we believe
these new procedures will lead, over time, to significant
reductions in the need to pursue appeals at the later stages of the
appeals system, such as ALJs and [Medicare Appeals Council]
reviews.”

Providers should visit their DMERC Web site to find where to
send requests for ALJ hearings based on fair hearing decisions
dated June 30 or later.

For more on Medicare appeals process reform, visit the HHS
Office of Medicare Hearings and Appeals Transition Web site,
available by clicking
here.