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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.

 

 

Appeal Eligibility

 

To be eligible for OMHA statistical sampling:

  • A request for hearing must appeal a Medicare Qualified Independent Contractor (QIC) reconsideration decision.
  • The appellant must be a single Medicare provider or supplier (if multiple providers or suppliers with multiple National Provider Identifiers (NPIs) are owned by a single entity, the owning entity may serve as “a single provider or supplier” provided that the owning entity agrees to accept any payment that may be due from Medicare as a single payment, or agrees to make any payment that may be due to Medicare as a single payment).
  • All jurisdictional requirements for a hearing before an Administrative Law Judge must be met for the request for hearing and all appealed claims.
  • The beneficiary must not have been found liable after the initial determination or participated in the QIC reconsideration.
  • The claims must be currently assigned to one or more Administrative Law Judges or have been filed during the time period currently being assigned by OMHA Central Operations – at this time, that includes appeals that were filed between April 1, 2013, and June 30, 2013.
  • No hearing on the claim has been scheduled or conducted.
  • There must be a minimum of 250 claims and all claims must fall into only one of the following categories:
    • Pre-payment claim denials;
    • Post-payment (overpayment) non-Recovery Audit Contractor (RAC) claim denials; or
    • Post-payment (overpayment) RAC claim denials from one RAC.
  • There cannot be an outstanding request for Settlement Conference Facilitation for the same claims.

 

Statistical Sampling Facts and Process

 

We encourage you to read this entire page and the Statistical Sampling Fact Sheet in the Downloads section before requesting statistical sampling or responding to an OMHA offer to conduct statistical sampling.

 

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.

 

Contact Us

 

If you have any questions regarding the OMHA statistical sampling pilot, you can submit your questions via email to OMHA.stat.sampling@hhs.gov.

 

Downloads

 

Statistical Sampling Fact Sheet

Request for Statistical Sampling Template

Claim Information Spreadsheet (Microsoft Excel)