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Statistical Sampling Initiative Update

The Office of Medicare Hearing and Appeals is pleased to announce several changes in the Statistical Sampling Program.  These changes are based on feedback received during the pilot phase of this program.  OMHA statistical sampling provides appellants with an option for addressing large volumes of claim disputes at the Administrative Law Judge hearing level of the Medicare claim appeals process.
The two major changes are:
 
  1. There is no longer a limitation on appeals that may be processed through statistical sampling based on when they were filed.  Criteria for determining if appeals otherwise qualify for this program may be found below.
  2. The appeal assignment process has changed.  Appeals will be assigned in accordance with random assignment principles to a lead Administrative Law Judge.  Administrative Law Judge(s) from the same field office will be assigned as follows:
  • If the universe size is 250-750 claims, a cadre of 2 additional Administrative Law Judges will be assigned. Each Administrative Law Judge will hear and decide one third of the statistical sample claims.
  • If the universe size is 750 claims or greater, a cadre of 3-4 additional ALJs will be assigned. Each Administrative Law Judge will hear and decide one quarter to one fifth of the statistical sample claims.
 
The Office of Medicare Hearing and Appeals hopes these changes make this program more attractive and that appellants actively consider participation in the program.  Additional information on this program may be found below.
 

Statistical Sampling Initiative

The OMHA Statistical Sampling Initiative is a pilot project providing appellants an additional means to handle large volumes of claim disputes at the third level. 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. Administrative Law Judges then review the sample units and make findings and a decision on those sample units.
 
There are two means by which Statistical Sampling at OMHA may be initiated: Appellant Request or OMHA Invitation. An OMHA statistical sampling coordinator (referred to as a Coordinator) will serve as the central point of contact with an appellant in securing the initial consent for statistical sampling, and ensuring sampling efforts are coordinated throughout OMHA.
 
Statistical sampling in the course of adjudicating appeals will be conducted only when an appellant explicitly agrees to statistical sampling, and where the sampling methodology employed is valid and protects the interests of both the appellant and the Medicare Trust Fund.  
A prehearing conference will be conducted by an Administrative Law Judge to confirm the universe of appeals for statistical sampling, set expectations and address other matters to facilitate the hearing. A prehearing conference order will be issued to confirm the appellant’s consent for statistical sampling, the universe, and other matters to be agreed upon at the conference. The appellant will be provided with a reasonable opportunity to object to the prehearing conference order before it becomes binding. After the prehearing conference order is issued and becomes binding, all appeals will be combined into a single appeal and assigned to a lead Administrative Law Judge and additional assigned Administrative Law Judges as follows:
  • If the universe size is 250-750 claims, a cadre of 2 additional Administrative Law Judges will be assigned. Each Administrative Law Judge will hear and decide one third of the statistical sample claims.
  • If the universe size is 750 claims or greater, a cadre of 3-4 additional ALJs will be assigned. Each Administrative Law Judge will hear and decide one quarter to one fifth of the statistical sample claims.
 
Each assigned ALJ will conduct a hearing on their portion of the sample units selected by the OMHA statistical expert.  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 the OMHA statistical expert 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 at the bottom of this page) 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 claims are determined to be ineligible for Statistical Sampling, you will receive a notification from the OHMA Statistical Sampling Coordinator. For more information on eligibility requirements, please review the Statistical Sampling Fact Sheet
 

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

Content created by Office of Medicare Hearings and Appeals (OMHA)
Content last reviewed on August 10, 2016