Name Arbiter Deadline Post-Payment Review Finds an Overpayment, and the Provider Step One Redetermination MAC (under CMS) 60 days Step Two Reconsideration QIC (under CMS) 60 days CMS May Begin Recoupment within 30 Days of the Reconsideration Decision Step Three Determination by ALJ ALJ (under OMHA) 90 days Step Four Determination by DAB DAB (under OMHA) 90 days Provider May Challenge the Overpayment in Federal Court B.
(97) When Congress created the RAP, it did not expand OMHA's budget to accommodate the predictable increase in appeals, (98) and as a result, providers blame this program for the System's ballooning delays.
Between 2009 and 2014, "the number of requests for an ALJ hearing or review increased 1,222%," (101) but the budget for OMHA, the office responsible for Medicare's ALJ appeals, increased by only sixteen percent from 2010 to 2014.
Among the massive backlog of hospital inpatient claim appeals at OMHA, CMS is giving providers the chance to settle up and get paid--at least somewhat.
Department of Health and Human Services Memorandum to OMHA Medicare Appellants (http://www.hhs.gov/omha/letter_to_medicare_appellants_from_the_calj.pdf)
The wait times reflect OMHAs
enormous backlog of appeals.
The backlogs were also a concern to the members of Congress, who found it "alarming" that the "OMHA
operates with 65 Administrative Law Judges, who already have 375,000 claims currently before them," according to the Feb.
(25) See OMHA 1990, supra note 22, s 39.1(6) (mandating the CCB to "promptly review" CTOs); HCCA, supra note 23, ss 75, 80 (providing for particularly short time frames for the CCB to schedule hearings and render decisions, and for appeals from those decisions to be filed).
(26) See OMHA 1990, supra note 22, s 39.1(9) (establishing that parties to CTO reviews by the CCB must include the ordering physician, the patient, and any third person specified by the CCB).
OMHA 1990, supra note 22, s 48(6) (allowing a physician to extend a discontinued certificate of involuntary admission by motion to the court).
"In 1994," according to Don Miner, executive director of OMHA, "several factories producing manufactured housing were considering locating in Oregon.
Miner says that in the interest of expedience "we tried to buy an off-the-shelf training program from another state, but we discovered that such a thing did not exist." Instead, OMHA worked with OEDD to create a partnership with Linn-Benton Community College, building on initial training programs developed for the newcomer factories to provide training for OMHA's entire membership.