The Civil Remedies Division
The Civil Remedies Division (CRD) is composed of Administrative Law Judges (ALJs), including a Chief ALJ and a support staff composed of attorneys and paralegals. The ALJs are qualified under the Federal Administrative Procedure Act to conduct hearings on the record. Generally, the ALJ decision is an initial decision that may be appealed to the Board. If the ALJ decision is not appealed, it is the final administrative decision.
CRD ALJs hold hearings in which parties may challenge the following types of actions:
- fraud and abuse determinations by the Office of the Inspector General (OIG) or the Centers for Medicare & Medicaid Services (CMS);
- provider/supplier enforcement and certification determinations by CMS;
- terminations of or refusal to grant or continue federal funding for alleged civil rights violations;
- Program Fraud Civil Remedies Act determinations;
- civil money penalty determinations by Social Security Administration (SSA);
- equal Access to Justice Act determinations relating to OIG proceedings.
CRD ALJs also provide hearings and issue initial agency decisions regarding civil money penalties proposed by CMS under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). These ALJ decisions may be reviewed by the CMS Administrator or his or her delegate. CRD ALJs also conduct hearings to review Local Coverage Determinations promulgated by Medicare contractors (including fiscal intermediaries and carriers). In addition, CRD ALJs provide hearings in certain debt collection cases brought by SSA, involving non-bargaining unit employees and debts, requiring an independent hearing officer.
Nature of the Caseload
The jurisdiction of the Division's ALJs includes appeals from civil monetary penalties (CMPs) and other enforcement actions taken by the CMS against nursing home providers, clinical laboratories, home health care agencies and other health care providers. Actions taken by Peer Review Organizations may also be appealed to the Division. In addition, the judges decide cases regarding exclusion actions and civil monetary penalties imposed by the HHS Inspector General (IG) involving individual and other health care practitioners, as well as the EMTALA or "anti-patient dumping" cases. Medicare beneficiaries may also seek CRD ALJ review of Local Coverage Determinations promulgated by Medicare contractors (including fiscal intermediaries and carriers). Also within the Division's jurisdiction are certain CMP actions taken by the IG for SSA. The division has a variety of other jurisdictions, including claims collection and certain Civil Rights and HIPAA cases. At this time, the majority of cases involve CMS sanctions against nursing homes. The second most significant caseload involves the HHS IG exclusion cases.
Case Resolution and Hearings
Appeals before the Division are resolved in various ways, including voluntary settlement by the parties, on-the-record submissions, or in-person hearings. Hearings are adversarial and may involve expert testimony. The proceedings are transcribed and typically followed by posthearing briefing. Although the Division is headquartered in Washington, DC, the ALJs and staff travel to locations throughout the United States to conduct hearings. The ALJs determine the time and place of the hearing; every effort is made to select a location which accommodates both parties. Decisions rendered by the Division's ALJs may be appealed to the Departmental Appeals Board and subsequently to the federal courts.
Regulations and Procedures
In general, the regulations governing cases in which CMS is a party are found at 42 CFR 498; the regulations governing cases in which the Inspector General is a party are found at 42 CFR 1005. Certain procedural guidelines issued by the Division may impose some additional requirements. Although the rules for both of these caseloads are similar in a number of respects, there are some notable differences. It is important when litigating a case before the Division to review and be thoroughly familiar with the specific regulations governing the case at hand, and its accompanying procedures.