Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim Appeals, 65660-65663 [2014-26214]
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Federal Register / Vol. 79, No. 214 / Wednesday, November 5, 2014 / Notices
Under the Federal Reserve Bank of
Atlanta heading, the entry for
IBERIABANK Corporation, Lafayette,
Louisiana, is revised to read as follows:
A. Federal Reserve Bank of Atlanta
(Chapelle Davis, Assistant Vice
President) 1000 Peachtree Street NE.,
Atlanta, Georgia 30309:
1. IBERIABANK Corporation,
Lafayette, Louisiana; to merge with
Florida Bank Group, Inc., and thereby
indirectly acquire Florida Bank, both in
Tampa, Florida.
Comments on this application must
be received by November 24, 2014.
Board of Governors of the Federal Reserve
System, October 30, 2014.
Michael J. Lewandowski,
Associate Secretary of the Board.
[FR Doc. 2014–26216 Filed 11–4–14; 8:45 am]
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GENERAL SERVICES
ADMINISTRATION
[Notice–WW1–2014–04; Docket No. 2014–
0003; Sequence No. 4]
World War One Centennial
Commission; Notification of Upcoming
Public Advisory Meeting
World War One Centennial
Commission, GSA.
ACTION: Meeting notice.
AGENCY:
Notice of this meeting is being
provided according to the requirements
of the Federal Advisory Committee Act,
5 U.S.C. App. 10(a)(2). This notice
provides the schedule and agenda for
the December 10, 2014 meeting of the
World War One Centennial Commission
(the Commission). The meeting is open
to the public.
DATES: Effective: December 10, 2014.
Meeting date: The meeting will be
held on Wednesday, December 10, 2014
starting at 12:30 p.m. Central Standard
Time (CST), and ending no later than
2:00 p.m. Central Standard Time (CST).
The meeting will be held at the Pritzker
Military Museum and Library at 104
South Michigan Avenue, Chicago, IL
60603. This location is handicapped
accessible. The meeting will be open to
the public and will also be available
telephonically. Persons wishing to listen
to the proceedings may dial 712–432–
1001 and enter access code 474845614.
Note this is not a toll-free number.
FOR FURTHER INFORMATION CONTACT:
Daniel S. Dayton, Designated Federal
Officer, c/o The Foundation for the
Commemoration of the World Wars, 701
Pennsylvania Avenue NW., 123,
Washington, DC 20004–2608 202–380–
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SUMMARY:
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0725 (note: this is not a toll-free
number).
Written Comments may be submitted
to the Commission and will be made
part of the permanent record of the
Commission. Comments must be
received by 5:00 p.m. Eastern Standard
Time (EST), December 4, 2014 and may
be provided by email to daniel.dayton@
worldwar1centennial.org.
SUPPLEMENTARY INFORMATION:
Background
The World War One Centennial
Commission was established by Public
Law 112–272, as a commission to
ensure a suitable observance of the
centennial of World War I, to provide
for the designation of memorials to the
service of members of the United States
Armed Forces in World War I, and for
other purposes. Under this authority,
the Committee will plan, develop, and
execute programs, projects, and
activities to commemorate the
centennial of World War I, encourage
private organizations and State and
local governments to organize and
participate in activities commemorating
the centennial of World War I, facilitate
and coordinate activities throughout the
United States relating to the centennial
of World War I, serve as a clearinghouse
for the collection and dissemination of
information about events and plans for
the centennial of World War I, and
develop recommendations for Congress
and the President for commemorating
the centennial of World War I. The
Commission does not have an
appropriation and operated solely on
donated funds.
Agenda: Wednesday, December 10,
2014.
Introductions and plans for today’s
meeting—Designated
Federal Officer.
Committee Reports.
Old Business.
New Business.
Public Comments.
Closing comments.
Dated: October 31, 2014.
Daniel S. Dayton,
Designated Federal Official, World War I
Centennial Commission.
(NIOSH), Centers for Disease Control
and Prevention, Department of Health
and Human Services (HHS).
ACTION: Notice.
HHS gives notice concerning
the final effect of the HHS decision to
designate a class of employees from the
General Atomics facility in La Jolla,
California, as an addition to the Special
Exposure Cohort (SEC) under the Energy
Employees Occupational Illness
Compensation Program Act of 2000.
FOR FURTHER INFORMATION CONTACT:
Stuart L. Hinnefeld, Director, Division
of Compensation Analysis and Support,
NIOSH, 1090 Tusculum Avenue, MS C–
46, Cincinnati, OH 45226–1938,
Telephone 877–222–7570. Information
requests can also be submitted by email
to DCAS@CDC.GOV.
SUPPLEMENTARY INFORMATION:
SUMMARY:
Authority: 42 U.S.C. 7384q(b). 42 U.S.C.
7384l(14)(C).
On September 25, 2014, as provided
for under the Secretary of HHS
designated the following class of
employees as an addition to the SEC:
All Atomic Weapons Employees who
worked for General Atomics at its facility in
La Jolla, California, during the period from
January 1, 1960, through December 31, 1969,
for a number of work days aggregating at least
250 work days, occurring either solely under
this employment or in combination with
work days within the parameters established
for one or more other classes of employees
included in the Special Exposure Cohort.
This designation became effective on
October 25, 2014. Therefore, beginning
on October 25, 2014, members of this
class of employees, defined as reported
in this notice, became members of the
SEC.
John Howard,
Director, National Institute for Occupational
Safety and Health.
[FR Doc. 2014–26340 Filed 11–4–14; 8:45 am]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
[OMHA–1401–NC]
[FR Doc. 2014–26298 Filed 11–4–14; 8:45 am]
Medicare Program; Administrative Law
Judge Hearing Program for Medicare
Claim Appeals
BILLING CODE 6820–95–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Final Effect of Designation of a Class
of Employees for Addition to the
Special Exposure Cohort
National Institute for
Occupational Safety and Health
AGENCY:
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Office of Medicare Hearings
and Appeals (OMHA), HHS.
ACTION: Request for information.
AGENCY:
This request for information
solicits suggestions for addressing the
substantial growth in the number of
requests for hearing being filed with the
SUMMARY:
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Federal Register / Vol. 79, No. 214 / Wednesday, November 5, 2014 / Notices
Office of Medicare Hearings and
Appeals, and backlog of pending cases.
DATES: The information solicited in this
notice must be received at the address
provided below, no later than 5:00 p.m.,
eastern standard time (e.s.t.) December
5, 2014.
ADDRESSES: In commenting, refer to
‘‘OMHA–1401–NC’’ at the top of your
comments. Because of staff and resource
limitations, we cannot accept comments
by facsimile (FAX) transmission. We
will not accept comments submitted
after the comment period.
You may submit comments in one of
two ways (to ensure that we do not
receive duplicate copies, please choose
only one of the ways listed):
1. Electronically. You may submit
electronic comments to
www.regulations.gov. For new users,
you can find instructions on how to
submit comments by selecting ‘‘Are you
new to this site?’’ at
www.regulations.gov, then selecting
‘‘How do I submit a comment?’’ For
those familiar with
www.regulations.gov, you can search
‘‘OMHA–1401–NC’’ and select
‘‘Comment Now!’’
If you are submitting comments
electronically, we strongly encourage
you to submit any comments or
attachments in Microsoft Word format.
If you must submit a comment in
Portable Document Format (PDF), we
strongly encourage you to convert the
PDF to print-to-PDF format or to use
some other commonly used searchable
text format. Please do not submit the
PDF in a scanned or read-only format.
Using a print-to-PDF format allows us to
electronically search and copy certain
portions of your submissions.
2. U.S. Mail or commercial delivery.
You may send written comments to the
following address only: Office of
Medicare Hearings and Appeals,
Department of Health and Human
Services, Attention: OMHA–1401–NC,
1700 N. Moore St., Suite 1800,
Arlington, VA 22209.
Please allow sufficient time for mailed
comments to be received before the
close of the comment period.
Viewing comments: Comments
received from members of the public
(including comments submitted by mail
or commercial delivery) will be made
available for public viewing in their
entirety on the Federal eRulemaking
portal at www.regulations.gov.
Information on using
www.regulations.gov, including
instructions for accessing agency
documents, submitting comments, and
viewing the docket, is available on the
site under ‘‘Are you new to the site?’’
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Privacy Note: Because comments will be
made available for public viewing in their
entirety on the Federal eRulemaking portal,
commenters should exercise caution and
only include in their comments information
that they wish to make publicly available.
FOR FURTHER INFORMATION CONTACT:
Jason Green, by telephone at 1–703–
235–0124, or by email at jason.green@
hhs.gov (comments will not be accepted
at this email address). If you use a
telecommunications device for the deaf
(TDD) or a text telephone (TTY), call the
Federal Relay Service (FRS), toll free, at
1–800–877- 8339.
SUPPLEMENTARY INFORMATION:
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,
organization and coverage
determination, and entitlement appeals
under sections 1869, 1155,
1876(c)(5)(B), 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, as well as Medicare
Advantage Organizations (MAOs) and
Medicaid State Agencies, have a fair and
impartial forum to address
disagreements with Medicare coverage
and payment determinations made by
Medicare contractors, MAOs, or Part D
Plan Sponsors (PDPSs), and
determinations related to Medicare
eligibility and entitlement, and incomerelated premium surcharges made by
the Social Security Administration
(SSA).
The Medicare claim, and organization
and coverage determination appeals
process consists of four levels of
administrative review within HHS, and
a fifth level of review with the Federal
courts after administrative remedies
within HHS have been exhausted. The
first two levels of review are
administered by the Centers for
Medicare & Medicaid Services (CMS)
and conducted by Medicare contractors
for claim appeals, by MAOs and an
independent review entity for Part C
organization determination appeals, or
by PDPSs and an independent review
entity for Part D coverage determination
appeals. The third level of review is
administered by OMHA and conducted
by Administrative Law Judges. The
fourth level of review is administered by
the HHS Departmental Appeals Board
(DAB) and conducted by the Medicare
Appeals Council. In addition, OMHA
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and the DAB administer the second and
third levels of appeal, respectively, for
Medicare eligibility, entitlement and
premium surcharge reconsiderations
made by SSA; a fourth level of review
with the Federal courts is available after
administrative remedies within HHS
have been exhausted.
The Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection
Act of 2000 (Pub. L. 106–554), which
added section 1869(d)(1)(A) of the
Social Security Act, provides for an
Administrative Law Judge to conduct
and conclude a hearing and render a
decision on such hearing within 90 days
of the date a request for hearing has
been timely filed. Section 1869(d)(3) of
the Social Security Act states that, if an
ALJ does not render a decision by the
end of the specified timeframe, the
appellant may request review by the
Departmental Appeals Board. Likewise,
if the Departmental Appeals Board does
not render a decision by the end of the
specified timeframe, the appellant may
seek judicial review. 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 SSA to
HHS. OMHA was expected to improve
service to appellants and reduce the
average 368-day waiting time for a
hearing decision that appellants
experienced with SSA.
OMHA serves a broad sector of the
public, including Medicare providers,
suppliers, and MAOs, and Medicare
beneficiaries, who are often elderly or
disabled and among the nation’s most
vulnerable populations. OMHA
currently administers its program in five
field offices, including those located in
Miami, Florida; Cleveland, Ohio; Irvine,
California; Arlington, Virginia; and the
recently established field office in
Kansas City, Missouri. OMHA uses
video-teleconferencing (VTC), telephone
conferencing, and in-person formats to
provide appellants with hearings.
At the time OMHA was established, it
was envisioned that OMHA would
receive the claim and entitlement
appeals workload from the Medicare
Part A and Part B programs, and
organization determination appeals
from the Medicare Advantage (Part C)
program, as well as coverage
determination appeals from the
Medicare Prescription Drug (Part D)
program and appeals of Income Related
Monthly Adjustment Amount (IRMAA)
premium surcharges assessed by SSA.
With this mix of work at the expected
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levels, OMHA was able to meet the 90day adjudication time frame.
However, in recent years, OMHA has
experienced a significant and sustained
increase in appeals workload that has
compromised its ability to meet the 90day adjudication time frame. In addition
to the expanding Medicare beneficiary
population and utilization of services
across that population, the increase in
appeals workload has resulted from a
number of changes in the Medicare
claim review and appeals processes in
recent years, including:
• Medicaid State Agency (MSA)
appeals of Medicare coverage denials for
beneficiaries dually enrolled in both
Medicare and Medicaid. These appeals
were previously addressed through a
demonstration project that employed an
alternative dispute resolution process to
determine whether the Medicare or
Medicaid program would pay for care
furnished to the dually enrolled
beneficiaries. The demonstration project
ended in 2010, and the MSA appeals
entered the standard administrative
appeals process, increasing appeals
workloads throughout the Medicare
claim appeal process, including at
OMHA.
• The fee-for-service Recovery Audit
(RA) program (also known as the
Recovery Audit Contractor program),
which was made permanent by section
302 of the Tax Relief and Health Care
Act of 2006 (Pub. L. 109–432). Appeals
from the RA program began to enter the
administrative appeals process at the
CMS contractor levels in fiscal year
2011. In fiscal year 2012, OMHA began
receiving hearing requests related to the
RA program that exceeded projections.
• CMS has implemented a number of
changes to enhance its monitoring of
payment accuracy in the Medicare Part
A and Part B programs, which have
increased denial rates and likely
contributed to increased appeals. For
example, based on recommendations
from the HHS Office of Inspector
General (OIG), in 2009, CMS tightened
its methodologies related to how it
calculates the Medicare payment error
rate, with a view towards improving
provider claims documentation and
compliance with Medicare’s billing,
coverage, and medical necessity
requirements. In addition, Medicare
Administrative Contractors (MACs)
initiated a series of focused medical
review initiatives, which increased the
overall number of denied claims. CMS
also initiated efforts to eliminate
payment error and fraud based on
Executive Order 13520 and the
Improper Payments Elimination and
Recovery Act of 2010 (Pub. L. 111–204),
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resulting in additional denied claims
and the identification of overpayments.
With the increase in overall claim
denials, the administrative appeals
process has experienced an overall
increase in appeal requests. At OMHA,
the more than anticipated workload
increase in appealed claims resulted in
a backlog of appeals (that is, appeals
that cannot be heard and decided within
the adjudication time frame) starting in
fiscal year 2012, with a 42% increase
from fiscal year 2011 in the number of
claims appealed to OMHA. In fiscal year
2013, the number of claims appealed to
OMHA more than doubled from fiscal
year 2012, with a 123% increase, further
contributing to the backlog of cases and
resulting in a substantial increase in the
adjudication time frame. The increase in
appealed claims from the RA program
was particularly high in fiscal year
2013, with a 506% increase in appealed
RA program claims compared to fiscal
year 2012 appealed claims from the RA
program, versus a 77% increase in
appealed claims not related to the RA
program during that same period of
time.
In 2013, CMS issued an Administrator
Ruling (published on March 18, 2013,
78 FR 16614) and finalized new rules
(published on August 19, 2013, 78 FR
50495) designed to clarify criteria for
new (fiscal year 2014) Medicare Part A
inpatient hospital admissions, which
comprised the disputed issues in a
majority of RA program appeals, and to
clarify policies at issue in appeals of
inpatient claim denials under the
existing rules. In addition, CMS
expanded the scope of alternative Part B
services that could be billed if a Part A
inpatient admission was denied and, as
part of the ruling, for a limited time
allowed hospitals to submit Part B
claims for those services beyond the
one-year claim filing deadline.
Separately, CMS also suspended most
RA program audits of Part A inpatient
hospital admissions under the new
inpatient admission criteria (commonly
referred to as the two-midnight rule),
which was effective for inpatient claims
with admission dates on and after
October 1, 2013, in order to offer
providers time to become educated on
the two-midnight rule. The suspension
of audits for new admissions was
extended for claims with dates of
admission through March 31, 2015,
pursuant to section 111 of the Protecting
Access to Medicare Act of 2014 (Pub. L.
113–93). CMS is also making
improvements to the RA program that
are designed to increase the accuracy of
RA determinations and to reduce the
burden on providers as well as the
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number of payment denials that
providers and suppliers appeal.
OMHA also took measures to mitigate
the effects of the workload increase at
the Administrative Law Judge level. One
of the immediate measures taken was to
ensure that processing of the relatively
small numbers of beneficiary-initiated
appeals was prioritized. For the
remaining cases, OMHA has deferred
assignments of new requests for hearing
until an adjudicator becomes available,
which will allow appeals 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.
On February 12, 2014, OMHA hosted
a Medicare Appellant Forum (see
OMHA’s Notice of Meeting, published
on January 3, 2014, 79 FR 393). The
Medicare Appellant Forum was
conducted to provide the appellant
community with an update on the status
of OMHA operations; relay information
on a number of OMHA initiatives
designed to mitigate the backlog in
processing Medicare appeals at the
Administrative Law Judge level of the
administrative appeals process; and
provide information on measures that
appellants could take to make the
administrative appeals process work
more efficiently at the Administrative
Law Judge level. In addition, CMS and
the DAB participated in the forum and
shared information on operations at
their respective appeals levels. A second
OMHA Medicare Appellant Forum was
held on October 29, 2014 (see OMHA’s
Notice of Meeting, published on October
23, 2014, 79 FR 63398). As conveyed at
the forums, HHS is committed to
addressing the challenges facing the
Medicare claim and entitlement appeals
process, and has implemented
initiatives and continues to explore
additional measures to address the
workload increase and reduce the
backlog of appeals.
Since the February Medicare
Appellant Forum, OMHA has
implemented two pilot programs to
provide appellants with meaningful
options to address claims at the
Administrative Law Judge level of
appeal, in addition to the existing right
to escalate a request for appeal when the
adjudication time frame is not met.
OMHA is providing appellants with an
option to use statistical sampling during
the Administrative Law Judge hearing
process, which will enable appellants to
obtain a decision on large numbers of
appealed claims based on a sampling of
those claims. OMHA is also providing
appellants with an option for settlement
conference facilitation, which will
provide appellants with an independent
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OMHA facilitator to discuss potential
settlement of claims with authorized
settlement officials. Additional
information on these two pilots can be
found on OMHA’s Web site, https://
www.hhs.gov/omha.
In addition to these initiatives, OMHA
continues to pursue new case
processing efficiencies and an electronic
case adjudication processing
environment (ECAPE) to bring further
efficiencies to the appeals process.
II. Request for Information
OMHA is seeking input from the
public on the current initiatives being
undertaken at the Administrative Law
Judge level, as well as suggestions for
additional initiatives which could be
undertaken at OMHA to address the
Medicare claim and entitlement appeals
workload and backlog at the
Administrative Law Judge level. Input is
sought on the following topics and
questions:
• Are there suggestions related to the
current initiatives for addressing the
increased workload and/or backlog of
appeals at the Administrative Law Judge
level that comply with current statutory
authorities and requirements?
• Are there other suggestions for
addressing the increased workload and/
or backlog of appeals at the
Administrative Law Judge level that
comply with current statutory
authorities and requirements?
• Are there any current regulations
that apply to the Administrative Law
Judge level of the Medicare claim and
entitlement appeals process that could
be revised to streamline the
adjudication process while ensuring
that parties to the appeals, as defined at
42 CFR 405.902 and 405.906, are
afforded opportunities to participate in
the process and are kept apprised of
appeals related to claims submitted by
them or on their behalf?
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(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)
Dated: October 30, 2014.
Nancy J. Griswold,
Chief Administrative Law Judge, Office of
Medicare Hearings and Appeals.
[FR Doc. 2014–26214 Filed 11–4–14; 8:45 am]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Administration for Children and
Families
[CFDA Number: 93.647]
Announcement of the Award of a
Single-Source Program Expansion
Supplement Grant to Child Trends,
Inc., in Bethesda, MD
Office of Planning, Research
and Evaluation, ACF, HHS.
ACTION: Announcement of the award of
a single-source expansion supplement
grant to Child Trends, Inc., in Bethesda,
MD, to support activities that promote
the economic and social well-being of
individuals, families, and communities.
AGENCY:
The Administration for
Children and Families (ACF), Office of
Planning, Research and Evaluation
(OPRE) announces the award of a singlesource expansion supplement award in
the amount of $120,000 to Child Trends,
Inc., in Bethesda, MD, to support
activities that will provide researchbased information to improve
understanding of how to promote the
economic and social well-being of
underserved and under-represented
populations.
DATES: September 30, 2014 through
September 29, 2015.
FOR FURTHER INFORMATION CONTACT: Ann
Rivera, Social Science Research Analyst,
Office of Planning, Research &
Evaluation, Administration for Children
and Families, 370 L’Enfant Promenade
SW., Washington, DC 20447; Telephone:
(202) 401–5506; Email: ann.rivera@
acf.hhs.gov.
SUPPLEMENTARY INFORMATION: Under this
grant program, Child Trends, Inc., a
non-profit, nonpartisan research center,
has established the National Research
Center on Hispanic Children and
Families, which brings together an
interdisciplinary team of academic and
organizational partners to provide
leadership in culturally competent
research that can inform policies
concerning low-income Hispanic
families and to foster significant
scholarship regarding the needs and
experiences of the Hispanic populations
throughout the nation. This ACFsponsored research center develops
research products and research-based
resources that aim to build research
capacity in the field and to improve
understanding of Hispanic populations
in order to inform policy development
and programmatic responses.
The award of a single-source
expansion supplement to this research
SUMMARY:
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center will support activities to develop
research-based resources to inform ACF
program offices, current and future ACF
grantees, and potential ACF grant
applicants about the characteristics and
needs of underserved and underrepresented populations.
Statutory Authority: Section 1110 of the
Social Security Act (42 U.S.C. 1310).
Melody Wayland,
Senior Grants Policy Specialist, Office of
Administration, Office of Financial Services/
Division of Grants Policy.
[FR Doc. 2014–26226 Filed 11–4–14; 8:45 am]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Food and Drug Administration
[Docket No. FDA–2014–N–1721]
Agency Information Collection
Activities; Proposed Collection;
Comment Request; Investigational
New Drug Applications
AGENCY:
Food and Drug Administration,
HHS.
ACTION:
Notice.
The Food and Drug
Administration (FDA) is announcing an
opportunity for public comment on the
proposed collection of certain
information by the Agency. Under the
Paperwork Reduction Act of 1995 (the
PRA), Federal Agencies are required to
publish notice in the Federal Register
concerning each proposed collection of
information, including each proposed
extension of an existing collection of
information, and to allow 60 days for
public comment in response to the
notice. This notice solicits comments on
regulations under which the clinical
investigation of the safety and
effectiveness of unapproved new drugs
and biological products can be
conducted.
DATES: Submit either electronic or
written comments on the collection of
information by January 5, 2015.
ADDRESSES: Submit electronic
comments on the collection of
information to https://
www.regulations.gov. Submit written
comments on the collection of
information to the Division of Dockets
Management (HFA 305), Food and Drug
Administration, 5630 Fishers Lane, Rm.
1061, Rockville, MD 20852. All
comments should be identified with the
docket number found in brackets in the
heading of this document.
FOR FURTHER INFORMATION CONTACT: FDA
PRA Staff, Office of Operations, Food
SUMMARY:
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Agencies
[Federal Register Volume 79, Number 214 (Wednesday, November 5, 2014)]
[Notices]
[Pages 65660-65663]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-26214]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1401-NC]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim Appeals
AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS.
ACTION: Request for information.
-----------------------------------------------------------------------
SUMMARY: This request for information solicits suggestions for
addressing the substantial growth in the number of requests for hearing
being filed with the
[[Page 65661]]
Office of Medicare Hearings and Appeals, and backlog of pending cases.
DATES: The information solicited in this notice must be received at the
address provided below, no later than 5:00 p.m., eastern standard time
(e.s.t.) December 5, 2014.
ADDRESSES: In commenting, refer to ``OMHA-1401-NC'' at the top of your
comments. Because of staff and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. We will not accept comments
submitted after the comment period.
You may submit comments in one of two ways (to ensure that we do
not receive duplicate copies, please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments to
www.regulations.gov. For new users, you can find instructions on how to
submit comments by selecting ``Are you new to this site?'' at
www.regulations.gov, then selecting ``How do I submit a comment?'' For
those familiar with www.regulations.gov, you can search ``OMHA-1401-
NC'' and select ``Comment Now!''
If you are submitting comments electronically, we strongly
encourage you to submit any comments or attachments in Microsoft Word
format. If you must submit a comment in Portable Document Format (PDF),
we strongly encourage you to convert the PDF to print-to-PDF format or
to use some other commonly used searchable text format. Please do not
submit the PDF in a scanned or read-only format. Using a print-to-PDF
format allows us to electronically search and copy certain portions of
your submissions.
2. U.S. Mail or commercial delivery. You may send written comments
to the following address only: Office of Medicare Hearings and Appeals,
Department of Health and Human Services, Attention: OMHA-1401-NC, 1700
N. Moore St., Suite 1800, Arlington, VA 22209.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
Viewing comments: Comments received from members of the public
(including comments submitted by mail or commercial delivery) will be
made available for public viewing in their entirety on the Federal
eRulemaking portal at www.regulations.gov. Information on using
www.regulations.gov, including instructions for accessing agency
documents, submitting comments, and viewing the docket, is available on
the site under ``Are you new to the site?''
Privacy Note: Because comments will be made available for public
viewing in their entirety on the Federal eRulemaking portal,
commenters should exercise caution and only include in their
comments information that they wish to make publicly available.
FOR FURTHER INFORMATION CONTACT: Jason Green, by telephone at 1-703-
235-0124, or by email at jason.green@hhs.gov (comments will not be
accepted at this email address). If you use a telecommunications device
for the deaf (TDD) or a text telephone (TTY), call the Federal Relay
Service (FRS), toll free, at 1-800-877- 8339.
SUPPLEMENTARY INFORMATION:
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,
organization and coverage determination, and entitlement appeals under
sections 1869, 1155, 1876(c)(5)(B), 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, as well as Medicare Advantage Organizations (MAOs) and
Medicaid State Agencies, have a fair and impartial forum to address
disagreements with Medicare coverage and payment determinations made by
Medicare contractors, MAOs, or Part D Plan Sponsors (PDPSs), and
determinations related to Medicare eligibility and entitlement, and
income-related premium surcharges made by the Social Security
Administration (SSA).
The Medicare claim, and organization and coverage determination
appeals process consists of four levels of administrative review within
HHS, and a fifth level of review with the Federal courts after
administrative remedies within HHS have been exhausted. The first two
levels of review are administered by the Centers for Medicare &
Medicaid Services (CMS) and conducted by Medicare contractors for claim
appeals, by MAOs and an independent review entity for Part C
organization determination appeals, or by PDPSs and an independent
review entity for Part D coverage determination appeals. The third
level of review is administered by OMHA and conducted by Administrative
Law Judges. The fourth level of review is administered by the HHS
Departmental Appeals Board (DAB) and conducted by the Medicare Appeals
Council. In addition, OMHA and the DAB administer the second and third
levels of appeal, respectively, for Medicare eligibility, entitlement
and premium surcharge reconsiderations made by SSA; a fourth level of
review with the Federal courts is available after administrative
remedies within HHS have been exhausted.
The Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (Pub. L. 106-554), which added section
1869(d)(1)(A) of the Social Security Act, provides for an
Administrative Law Judge to conduct and conclude a hearing and render a
decision on such hearing within 90 days of the date a request for
hearing has been timely filed. Section 1869(d)(3) of the Social
Security Act states that, if an ALJ does not render a decision by the
end of the specified timeframe, the appellant may request review by the
Departmental Appeals Board. Likewise, if the Departmental Appeals Board
does not render a decision by the end of the specified timeframe, the
appellant may seek judicial review. 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 SSA to
HHS. OMHA was expected to improve service to appellants and reduce the
average 368-day waiting time for a hearing decision that appellants
experienced with SSA.
OMHA serves a broad sector of the public, including Medicare
providers, suppliers, and MAOs, and Medicare beneficiaries, who are
often elderly or disabled and among the nation's most vulnerable
populations. OMHA currently administers its program in five field
offices, including those located in Miami, Florida; Cleveland, Ohio;
Irvine, California; Arlington, Virginia; and the recently established
field office in Kansas City, Missouri. OMHA uses video-teleconferencing
(VTC), telephone conferencing, and in-person formats to provide
appellants with hearings.
At the time OMHA was established, it was envisioned that OMHA would
receive the claim and entitlement appeals workload from the Medicare
Part A and Part B programs, and organization determination appeals from
the Medicare Advantage (Part C) program, as well as coverage
determination appeals from the Medicare Prescription Drug (Part D)
program and appeals of Income Related Monthly Adjustment Amount (IRMAA)
premium surcharges assessed by SSA. With this mix of work at the
expected
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levels, OMHA was able to meet the 90-day adjudication time frame.
However, in recent years, OMHA has experienced a significant and
sustained increase in appeals workload that has compromised its ability
to meet the 90-day adjudication time frame. In addition to the
expanding Medicare beneficiary population and utilization of services
across that population, the increase in appeals workload has resulted
from a number of changes in the Medicare claim review and appeals
processes in recent years, including:
Medicaid State Agency (MSA) appeals of Medicare coverage
denials for beneficiaries dually enrolled in both Medicare and
Medicaid. These appeals were previously addressed through a
demonstration project that employed an alternative dispute resolution
process to determine whether the Medicare or Medicaid program would pay
for care furnished to the dually enrolled beneficiaries. The
demonstration project ended in 2010, and the MSA appeals entered the
standard administrative appeals process, increasing appeals workloads
throughout the Medicare claim appeal process, including at OMHA.
The fee-for-service Recovery Audit (RA) program (also
known as the Recovery Audit Contractor program), which was made
permanent by section 302 of the Tax Relief and Health Care Act of 2006
(Pub. L. 109-432). Appeals from the RA program began to enter the
administrative appeals process at the CMS contractor levels in fiscal
year 2011. In fiscal year 2012, OMHA began receiving hearing requests
related to the RA program that exceeded projections.
CMS has implemented a number of changes to enhance its
monitoring of payment accuracy in the Medicare Part A and Part B
programs, which have increased denial rates and likely contributed to
increased appeals. For example, based on recommendations from the HHS
Office of Inspector General (OIG), in 2009, CMS tightened its
methodologies related to how it calculates the Medicare payment error
rate, with a view towards improving provider claims documentation and
compliance with Medicare's billing, coverage, and medical necessity
requirements. In addition, Medicare Administrative Contractors (MACs)
initiated a series of focused medical review initiatives, which
increased the overall number of denied claims. CMS also initiated
efforts to eliminate payment error and fraud based on Executive Order
13520 and the Improper Payments Elimination and Recovery Act of 2010
(Pub. L. 111-204), resulting in additional denied claims and the
identification of overpayments.
With the increase in overall claim denials, the administrative
appeals process has experienced an overall increase in appeal requests.
At OMHA, the more than anticipated workload increase in appealed claims
resulted in a backlog of appeals (that is, appeals that cannot be heard
and decided within the adjudication time frame) starting in fiscal year
2012, with a 42% increase from fiscal year 2011 in the number of claims
appealed to OMHA. In fiscal year 2013, the number of claims appealed to
OMHA more than doubled from fiscal year 2012, with a 123% increase,
further contributing to the backlog of cases and resulting in a
substantial increase in the adjudication time frame. The increase in
appealed claims from the RA program was particularly high in fiscal
year 2013, with a 506% increase in appealed RA program claims compared
to fiscal year 2012 appealed claims from the RA program, versus a 77%
increase in appealed claims not related to the RA program during that
same period of time.
In 2013, CMS issued an Administrator Ruling (published on March 18,
2013, 78 FR 16614) and finalized new rules (published on August 19,
2013, 78 FR 50495) designed to clarify criteria for new (fiscal year
2014) Medicare Part A inpatient hospital admissions, which comprised
the disputed issues in a majority of RA program appeals, and to clarify
policies at issue in appeals of inpatient claim denials under the
existing rules. In addition, CMS expanded the scope of alternative Part
B services that could be billed if a Part A inpatient admission was
denied and, as part of the ruling, for a limited time allowed hospitals
to submit Part B claims for those services beyond the one-year claim
filing deadline. Separately, CMS also suspended most RA program audits
of Part A inpatient hospital admissions under the new inpatient
admission criteria (commonly referred to as the two-midnight rule),
which was effective for inpatient claims with admission dates on and
after October 1, 2013, in order to offer providers time to become
educated on the two-midnight rule. The suspension of audits for new
admissions was extended for claims with dates of admission through
March 31, 2015, pursuant to section 111 of the Protecting Access to
Medicare Act of 2014 (Pub. L. 113-93). CMS is also making improvements
to the RA program that are designed to increase the accuracy of RA
determinations and to reduce the burden on providers as well as the
number of payment denials that providers and suppliers appeal.
OMHA also took measures to mitigate the effects of the workload
increase at the Administrative Law Judge level. One of the immediate
measures taken was to ensure that processing of the relatively small
numbers of beneficiary-initiated appeals was prioritized. For the
remaining cases, OMHA has deferred assignments of new requests for
hearing until an adjudicator becomes available, which will allow
appeals 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.
On February 12, 2014, OMHA hosted a Medicare Appellant Forum (see
OMHA's Notice of Meeting, published on January 3, 2014, 79 FR 393). The
Medicare Appellant Forum was conducted to provide the appellant
community with an update on the status of OMHA operations; relay
information on a number of OMHA initiatives designed to mitigate the
backlog in processing Medicare appeals at the Administrative Law Judge
level of the administrative appeals process; and provide information on
measures that appellants could take to make the administrative appeals
process work more efficiently at the Administrative Law Judge level. In
addition, CMS and the DAB participated in the forum and shared
information on operations at their respective appeals levels. A second
OMHA Medicare Appellant Forum was held on October 29, 2014 (see OMHA's
Notice of Meeting, published on October 23, 2014, 79 FR 63398). As
conveyed at the forums, HHS is committed to addressing the challenges
facing the Medicare claim and entitlement appeals process, and has
implemented initiatives and continues to explore additional measures to
address the workload increase and reduce the backlog of appeals.
Since the February Medicare Appellant Forum, OMHA has implemented
two pilot programs to provide appellants with meaningful options to
address claims at the Administrative Law Judge level of appeal, in
addition to the existing right to escalate a request for appeal when
the adjudication time frame is not met. OMHA is providing appellants
with an option to use statistical sampling during the Administrative
Law Judge hearing process, which will enable appellants to obtain a
decision on large numbers of appealed claims based on a sampling of
those claims. OMHA is also providing appellants with an option for
settlement conference facilitation, which will provide appellants with
an independent
[[Page 65663]]
OMHA facilitator to discuss potential settlement of claims with
authorized settlement officials. Additional information on these two
pilots can be found on OMHA's Web site, https://www.hhs.gov/omha.
In addition to these initiatives, OMHA continues to pursue new case
processing efficiencies and an electronic case adjudication processing
environment (ECAPE) to bring further efficiencies to the appeals
process.
II. Request for Information
OMHA is seeking input from the public on the current initiatives
being undertaken at the Administrative Law Judge level, as well as
suggestions for additional initiatives which could be undertaken at
OMHA to address the Medicare claim and entitlement appeals workload and
backlog at the Administrative Law Judge level. Input is sought on the
following topics and questions:
Are there suggestions related to the current initiatives
for addressing the increased workload and/or backlog of appeals at the
Administrative Law Judge level that comply with current statutory
authorities and requirements?
Are there other suggestions for addressing the increased
workload and/or backlog of appeals at the Administrative Law Judge
level that comply with current statutory authorities and requirements?
Are there any current regulations that apply to the
Administrative Law Judge level of the Medicare claim and entitlement
appeals process that could be revised to streamline the adjudication
process while ensuring that parties to the appeals, as defined at 42
CFR 405.902 and 405.906, are afforded opportunities to participate in
the process and are kept apprised of appeals related to claims
submitted by them or on their behalf?
(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)
Dated: October 30, 2014.
Nancy J. Griswold,
Chief Administrative Law Judge, Office of Medicare Hearings and
Appeals.
[FR Doc. 2014-26214 Filed 11-4-14; 8:45 am]
BILLING CODE 4150-46-P