Office of Medicare Hearings and Appeals Adjudicatory Pilot Programs

Blog Post Co-Authored by Amber Williams and Megan Gibson:

The Office of Medicare Hearing Appeals (OMHA), located in the Department of Health and Human Services (HHS), is tasked with administering a national hearing program for Medicare claims. OMHA provides the forum in which those dissatisfied with a previous decision about Medicare benefits or eligibility may appeal.  Although the appeals process was originally established at HHS to improve service and reduce wait times, the number of appeals OMHA received accelerated in 2011 and has continued to accelerate at a dramatic pace.  This rise in hearing requests is primarily due to the increase in both new audit workloads and the number of Medicare beneficiaries.

In response to this sudden increase, OMHA has implemented two key initiatives to reduce the backlog.  First, OMHA created a statistical sampling program that facilitates the adjudication of claims on a large scale.  The program involves: (1) identifying a statistically valid sample from a pool of claims; (2) making a decision about that sample; and (3) applying that decision to the entire pool of claims.  Appellants may request statistical sampling on their own or accept an offer by OMHA to use statistical sampling.  Second, OMHA implemented a settlement conference facilitation program.  This program is an alternative dispute resolution process that brings the appellant and the Centers for Medicare and Medicaid Services together to resolve claims.  If both parties reach an agreement, the request for a hearing on those claims is dismissed.

Congress created OMHA with the purpose of both simplifying and improving the efficiency of the appeals process.  In the face of its overwhelming backlog, OMHA’s initiatives work to further the agency’s mission.