Statistical Sampling Initiative
OMHA statistical sampling is a pilot to provide appellants with an option for addressing large volumes of claim disputes at the Administrative Law Judge hearing level of the Medicare claim appeals process. Statistical sampling draws a random sample from a universe of claims and extrapolates (in other words, projects) the results of the sample to the entire universe of claims. OMHA statistical sampling is conducted using a trained and experienced statistical expert to develop the appropriate sampling methodology in accordance with Medicare guidance, and randomly select the sample units. An Administrative Law Judge then reviews the sample units and makes findings and a decision on those sample units.
During the pilot, statistical sampling conducted at OMHA may be initiated by an appellant request or in response to an OMHA offer. An OMHA statistical sampling coordinator will serve as the central point of contact with an appellant in securing the initial consent for statistical sampling, and ensures sampling efforts are coordinated throughout OMHA.
A pre-hearing conference will be conducted by an Administrative Law Judge to confirm consent for statistical sampling and address other matters to facilitate the hearing. After the pre-hearing conference order is issued and becomes binding, all appeals will be combined into a single appeal and assigned to a new Administrative Law Judge for a hearing on the sample units selected by the OMHA statistical expert (unless all of the appeals were originally assigned to a single Administrative Law Judge and that Administrative Law Judge conducted the pre-hearing conference). After a hearing is conducted and a decision is issued, the decision on the sample units will be extrapolated to the universe of claims by a CMS contractor and the decision will be effectuated based on the extrapolated amount.
Requesting Statistical Sampling Conducted at OMHA
If you wish to request statistical sampling, you must complete a written request for statistical sampling and a spreadsheet providing detailed information about the claims that you would like to be considered for the sampling process. While the use of the pre-formatted request template (see Downloads section) is not required, the information requested in the template is required. The claim information spreadsheet format must be Microsoft Excel compatible and submitted in its native format on a disc (for example, do not convert to a portable document format (PDF)).
In addition to completing the request and information spreadsheet, you will be required to submit your written consent to the use of statistical sampling. A consent template will be sent to you after your request is reviewed.
If your request cannot be acted upon, you will receive a notice from the OMHA statistical sampling coordinator.
If you have any questions regarding the OMHA statistical sampling pilot, you can submit your questions via email to OMHA.firstname.lastname@example.org.