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Effective Appeals from the ALJ Perspective


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Effective Appeals from the ALJ Perspective Handout, 9-29-2010

Judge Irwin Schroeder (Administrative Law Judge) provides insight on how to file an effective provider appeal.

Published in: Health & Medicine
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Effective Appeals from the ALJ Perspective

  1. 1. Lets start Introducing Administrative Law Judge Irwin Schroeder Managing Judge of Mid-Atlantic Hearing Office Mid Atlantic Office of Medicare Hearings and Appeals Arlington, Virginia g , g
  2. 2. PATH TO ALJ HEARING Federal Court MAC (HHS level) ALJ Hearing (OMHA) Reconsideration (QIC) Redetermination (FI) R d t i ti Initial Determination (FI)
  3. 3. What is different at ALJ level Difference in Decision Maker A. First federal employee B. First experienced judge C. First unrelated to CMS Difference in Record A. First oral hearing B. First opportunity to confront . s oppo u y o co o C. First independent expert
  4. 4. OMHA Organization g
  5. 5. Average case time g
  6. 6. ALJ Hearing History g y 159.1 FY10 Disposition per Day 140.8 FY09 ns FY08 119.4 FY07 117.0 174.0 FY10 Receipt per Day FY09 146.1 131.3 131 3 ts FY08 92.7 FY07 0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0 180.0
  7. 7. What to Expect at ALJ Level p 1. A decision in 90 days or less – Unless you need more time to prepare 2. 2 Ability to present expert testimony on A. Medical practices and concepts B. Business practices and consequences C. Statistical concepts and theories 3. 3 Time to argue any relevant facts and law
  8. 8. What to Expect at ALJ Level p 4. Varied hearing formats at your option A. Telephone – most favor B. Video Teleconference – at our expense C. In person – at hearing office or other D. Mixed format – e.g. Counsel in person witness on the g p telephone
  9. 9. What is in your request? y q 1. Information required by the regulation 42 CFR 405.1014 2. Concise theory of why you should be paid 3. List of few documents you must have 4. 4 List of witnesses you will offer Value of their testimony Documents they need
  10. 10. Where are CMS and contractors 1. Participation by CMS, QIC and other contractors is optional 2. CMS has a unit in Baltimore which monitors appeals 3. QIC and CMS can petition MAC for review of ALJ decisions
  11. 11. Purpose for ALJ Hearing p g 1. Arguments of Policy and Legal Issues 2. Clarification of Record Documents Illegible Professional vocabulary and usage Sequence of events 3. Receive evidence not previously submitted for good cause 4. Drama and Catharsis
  12. 12. Submission of Evidence Initial Determination – All Electronic Redetermination – First look at LCD Need Reconsideration – Last easy place ALJ Hearing – Oral Explanation and Expert Testimony without showing good cause
  13. 13. Preparation for Hearing p g How common is this claim type? How medical is this claim? How legalistic is this claim? How mechanical is this claim? How H expensive i this claim? i is hi l i ?
  14. 14. Rules of Decision 1. Social Security Act and amendments 2. Regulations at 42 CFR 400 and following 3. 3 NCDs issued by CMS through public process and opportunity to appeal 4. 4 LCDs issued by Carriers with notice to the public 5. Interpretations of the above
  15. 15. What is not for ALJ Hearing g 1. Any decision other than an initial determination 2. A challenge to a payment schedule 3. 3 A challenge to the requirements of an NCD or an LCD 4. 4 A challenge to the decision to extrapolate from a statistical sample 5. 5 A challenge to the decision to reopen