HHS FY2016 Budget in Brief
Office of the Secretary, Office of Medicare Hearings and Appeals (OMHA)
The Office of Medicare Hearings and Appeals provides an independent forum for the fair and efficient adjudication of Medicare appeals for beneficiaries and other parties. This mission is carried out by a cadre of knowledgeable Administrative Law Judges (ALJ) exercising judicial and decisional independence under the Administrative Procedures Act, with the support of a professional, legal, and administrative staff.
OMHA Budget Overview
(Dollars in millions)
|Budget Authority and Proposed Laws||2014||2015||2016||2016
|Recovery Audit Collections||0||0||125||+125|
|Refundable Filing Fee||0||0||5||+5|
|Total Program Level, OMHA||82||87||270||+183|
Full Time Equivalents
2016 +/- 2015: +911
The FY 2016 Budget request for the Office of Medicare Hearings and Appeals (OMHA) is $140 million, an increase of $53 million over FY 2015. The Budget request also includes a legislative package to address the growing backlog of Medicare appeals. HHS estimates that enactment of this package would provide an additional $125 million in Recovery Audit collections, and $5 million from a proposed refundable filing fee. OMHA administers hearings and appeals nationwide for the Medicare program. By statute, these Medicare appeals are to be heard within 90 days after receipt of a request for a hearing from a Medicare appellant.
Due to the overwhelming growth in its workload, OMHA has not been able to meet the required 90 day timeframe for case adjudication. It currently takes over 400 days for OMHA to adjudicate an appeal. At current resource levels, OMHA’s backlog of appeals is projected to reach 1,000,000 by the end of FY 2016. To address these challenges, OMHA has taken a number of administrative actions to reduce the pending appeals workload. For example, OMHA recently began to pilot settlement conference facilitations which offer alternative dispute resolution as a way to resolve pending cases without an Administrative Law Judge hearing. In addition, OMHA has made statistical sampling available to appellants, which has the potential to resolve large numbers of cases based on representative samples. While helpful, these steps taken alone are insufficient to keep up with the dramatic growth in claims.
The Budget request includes a comprehensive legislative package aimed at both helping HHS process a greater number of appeals and reducing the number of appeals filed. Please refer to the Centers for Medicare & Medicaid Services narrative for a comprehensive discussion of the appeals proposals.
With a funding level of $270 million, OMHA will open new field offices and hire additional adjudicators and support staff. OMHA will continue to utilize technology to offer appellants access to multiple hearing venues and services. These additional resources are critical for OMHA to respond to the increasing number of appeals while maintaining the quality and accuracy of its decisions, and ultimately, to restore the agency’s ability to provide timely hearings for Medicare appellants.
OMHA administers appeals in five field offices: Miami, Florida; Cleveland, Ohio; Irvine, California; Arlington, Virginia; and the recently opened Kansas City office. OMHA extensively utilizes hearings held via video teleconference and telephone in order to provide appellants with accessible hearings at low cost.
OMHA began processing cases on July 1, 2005; since then, it has received approximately 3 million claims nationwide for Medicare Parts A, B, C, and D appeals, as well as for Medicare entitlement and eligibility appeals. In FY 2011, OMHA began receiving additional claims resulting from the permanent nationwide expansion of the Recovery Audit program, administered by CMS. These claims, in addition to the more traditional Part A and B claims, have contributed to OMHA’s significant workload increase. OMHA received a total of 655,000 claims in FY 2013, and close to 1,000,000 claims in FY 2014. OMHA projects that its FY 2015 caseload will increase to approximately 1,200,000 claims (an 83 percent increase over FY 2013).
HHS Three-Pronged Medicare Appeals Process Improvement Strategy
- Invest new resources at all levels of appeal to increase adjudication capacity and implement new strategies to alleviate the current backlog
- Take administrative actions to reduce the number of pending appeals and prevent new cases from entering the system
- Propose legislative reforms that provide additional funding and new authorities to increase efficiency and address the volume of incoming appeals.