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OIG: Medicare should improve appeals at ALJ level

November 21, 2012

Administrative law judges reversed decisions by qualified independent contractors and decided fully in favor of appellants in 56% of appeals of Medicare decisions related to claims for health care services and items in fiscal year 2010, according to a report released last week by the Department of Health and Human Services' Office of Inspector General. ALJs differed from QICs in their interpretation of Medicare policies, their degree of specialization and their use of clinical experts, OIG found. Among other actions, the report recommends that the Office of Medicare Hearings and Appeals and Centers for Medicare & Medicaid Services provide coordinated training on Medicare policies to ALJs and QICs who decide appeals; identify and clarify Medicare policies that are unclear and interpreted differently; and revise regulations to provide more guidance to ALJs regarding the acceptance of new evidence. In addition, OIG recommends that OMHA implement a quality assurance process to review ALJ decisions, and determine whether specialization among ALJs would improve consistency and efficiency. It also recommends that CMS increase its participation in ALJ appeals. When CMS participated, ALJs were less likely to decide fully in favor of appellants, the report notes.