Medicare Administrative Contractors to Increase Participation in ALJ Hearings
October 7, 2014 12:08 PM
The Centers for Medicare & Medicaid Services (CMS) has issued Change Request (CR) 8501 - Defending Medicare Review Decisions at Administrative Law judge (ALJ) Hearings. In the CR, CMS instructs the Medicare Administrative Contractors (MACs) to take a more active role in medical review appeals that reach the ALJ level and how they should coordinate with the Qualified Independent Contractor (QIC) to receive the notice of hearing. The MACs may be a participant or a party to an ALJ hearing as outlined in 42 CFR 405.1010 and 405.1012.
If the contractor elects to participate or be a party to a hearing, it advises the ALJ, the appellant, and all other parties identified in the notice of hearing of its intent to participate no later than 10 calendar days after receiving the notice of hearing. Participation may include filing position papers or providing testimony to clarify factual or policy issues in a case, but it does not include calling witnesses or cross-examining the witnesses. As a party to the hearing, the contractor may file position papers, provide testimony to clarify factual or policy issues, call witnesses or cross-examine the witnesses of other parties.
The MACs must obtain approval from CMS prior to electing party status. In the event that CMS does not approve the MAC’s request for party status, the MAC may elect to proceed as a participant.
The MACs are to establish a process for assessing the notices of hearing received to determine which cases should be selected for participation at the ALJ level of appeal.
Factors to be considered, but not be limited to, are:
Dollars at issue,
Source of the denial,
Program integrity matters and,
Extent to which a particular issue is, or has been, a recurring issue at the ALJ level of appeal.
CMS instructs the MACs to actively participate in the ALJ hearing as appropriate based on participation status (participant or party). In either situation, the MAC are to be prepared to discuss details related to the facts of each claim under appeal, the relevant coverage policies and payment requirements, including any clarification required on decisions made earlier in the appeals process. For extrapolation cases, the MACs should be prepared to discuss the background on how the provider/supplier was selected for review, results of the sample case adjudications, as well as matters related to the extrapolation process.
It is unclear why CMS has issued this directive to the contractors at this time. It might be in response to the high number of appeals currently at the ALJ level along with a history of favorable decisions towards appellants by ALJs. Regardless of CMS’ motivation, all Medicare providers should see greater involvement of the MACs in ALJ appeal hearings.
Click here to view the Change Request.