Nature of the Caseload
The ALJs’ jurisdiction includes appeals from civil monetary penalties (CMPs) and other enforcement actions taken by the Centers for Medicare & Medicaid Services (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 an ALJ. In addition, the judges decide cases regarding exclusion actions and CMPs imposed by the HHS Office of the Inspector General (HHS IG) involving individual and other health care practitioners, CMPs and No Sale Tobacco Orders imposed by the Center for Tobacco Products (CTP), as well as the EMTALA or "anti-patient dumping" cases.
ALJs hold hearings in which parties may challenge the following types of actions:
- fraud, abuse and non-compliance determinations by the HHS IG or CMS;
- provider/supplier Medicare enrollment and revocation determinations by CMS;
- terminations of or refusal to grant or continue federal funding for alleged civil rights violations;
- Program Fraud Civil Remedies Act determinations;
- CMP determinations by the Social Security Administration (SSA) by interagency agreement;
- CMP complaints and No Sale Tobacco Orders by CTP by interagency agreement; and
- Equal Access to Justice Act determinations relating to HHS IG proceedings.
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. ALJs also conduct hearings to review Local Coverage Determinations (LCDs) promulgated by Medicare contractors, including fiscal intermediaries and carriers. In addition, ALJs provide hearings in certain debt collection cases brought by SSA and HHS, involving non-bargaining unit employees and debts requiring an independent hearing officer. The ALJs’ decisions in these cases represent the final agency decision.
Case Resolution and Hearings
The ALJs’ cases 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 post-hearing briefing. Although the Division is headquartered in Washington, DC, the ALJs conduct hearings through the use of video teleconferencing (VTC) technology. The ALJs determine the time and place of the hearing and every effort is made to select a VTC location which accommodates all parties and witnesses. Most decisions rendered by the 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 C.F.R. Part 498; LCD review is governed by 42 C.F.R. Part 426; the regulations governing cases in which the HHS IG is a party are found at 42 C.F.R. Part 1005; the regulations governing cases in which CTP is a party are found at 21 C.F.R. Part 17; and 20 C.F.R. Part 498 applies in those cases where the SSA IG is a party. The Civil Remedies Division Procedures and the ALJs’ prehearing orders may impose some additional requirements. Although the rules for these caseloads are similar in a number of respects, there are some notable differences. It is important when litigating a case before an ALJ to review and be thoroughly familiar with the CRD procedures (including e-filing requirements, if applicable) and specific regulations governing the case.
Department of Health & Human Services
Departmental Appeals Board, MS 6132
Civil Remedies Division
330 Independence Ave., S.W.
Cohen Building, Room G-644
Washington, DC 20201