Buried in Paper, Medicare Appeals to Go Electronic

After 7 years of operation, the Office of Medicare Hearings and Appeals (OMHA) has found itself buried in paper, so it now finds itself looking for ways to streamline its caseload  by becoming all digital, all the time.

The U.S. Department of Health and Human Services created OMHA as a mechanism to manage what it knew would be an increased number of appeals, the result of the Medicare Modernization Act of 2003. In the previous federal fiscal year, OMHA’s 475 employees and affiliated contractors processed 375,000 claims, double the previous year — all on paper.

There are five levels of appeal, and each has its own data processing systems, resulting in a Frankenstein’s monster of data vendors, all with limited interactivity. At the core of all the levels of appeal is the Medicare Appeals System (MAS) data repository, based in Baltimore. While the MAS serves as the data backbone for the appeals process, its functionality is limited and is unable to fully serve the requirements of all the levels of appeal.

The worst offender is the Administrative Law Judge part of the appeal process, which a recent investigation by the Office of Inspector General found rife with inefficiencies.

OMHA now is seeking information “on available commercial off the shelf products/solutions and ancillary services for implementation and support of the Electronic Case Processing Environment (ECPE) to substantially improve the delivery and efficiency of appeals processing services.” This represents only the beginning of the process to move all electronic, and will be many months, if not years, before it has an all digital workflow.

The Paper Trail

OMHA currently relies upon the following paper-based workflow:

1. Medicare claims are denied by Medicare Administrative Contractors. Healthcare providers can ask for a redetermination, which is done by the same contractors. If the contractor upholds the denial, the provider has the option of filing an appeal, beginning the cavalcade of paper.
2. Medicare appellants submit a paper request for hearing and supporting documentation to OMHA. Upon receiving the request at the Central Operations Division in Cleveland, OH, OMHA staff assign and forward the request to a field office team and fax a request for the case file to OMHA’s Qualified Independent Contractors (QICs), who conduct an “independent review of medical necessity issues.”
3. QIC print out a copy of the original electronic case file and ship it to the field office that the case was assigned to.
4. Upon receipt of the case file, OMHA field office staff retrieve the paper request for hearing out of storage and deliver both files to the next step in the process, the office of an Administrative Law Judge (ALJ).
5. The ALJ’s legal assistant organizes the file into sections and tabs each section in a process called exhibiting, then places the exhibited file in storage awaiting review.
6. An ALJ attorney reviews the case file making notes for the judge.
7. If a hearing is required, the legal assistant manually schedules the hearing and creates a Notice of Hearing and mails it to all applicable parties.
8. The judge holds the hearing using the paper case file and makes an audio recording of the proceedings.
9. The judge writes decision instructions for the attorney.
10. The attorney drafts the decision and gives it to the judge for review and signature.
11. The signed decision is given to the legal assistant who mails copies to the parties.
12. The legal assistant ships the audio CD of the hearing, a copy of the decision and the case file to the Administrative Qualified Independent Contractor (AdQIC).
13. The AdQIC effectuates the decision and ships the case file to a storage location.
14. If the case is appealed to the next level — the Department Appeals Board (DAB) — the AdQIC ships the case file to the DAB.

A New Electronic Workflow

OMHA has listed the type of functionality it wants in a digital workflow, including:

• Dynamic workflow, configurable largely without coding, including task based user interfaces and task and workload tracking/management.
• Data management including extensive rules-based calculations, data validation, process initiation, and action/deadline alerts.
• Electronic document management including document capture, automatic classification/categorization and indexing of structured and unstructured documents, extensive document/file structuring/restructuring, document storage, and document deletion.
• Electronic document manipulation and presentation (exhibiting) including splitting, excerpting, duplicate identification, page reordering, search capabilities, permanent stamping, locking, multiple factor indexing, annotating, bookmarking and highlighting.
• Correspondence generation, which involves merging data with template-based and ad-hoc content; and decision generation, which also involves dynamic logic-based construction of decisions from both stored and ad-hoc content.
• Seamless interfaces with the Medicare Appeals System including its component/supporting systems (Oracle database, IBM Content Manager, Kofax document capture) as well as a number of feeder systems providing data regarding claims, providers, beneficiaries, etc.
• Role-based profiles regarding external parties and participants to the appeal such as appellants, providers, beneficiaries, medical experts, MACs, QICs, etc. These profiles will be essential to rules-based determinations regarding receipt of notifications, decisions, specific data to be included within notifications and decisions, etc.
• Scheduling of hearings, resources, and internal (e.g. ALJs) and external participants.
• Secure web-based electronic filing and access to appeal status information and case documents.
• Robust reporting, business intelligence, and analytics.
• Processing and storage (data, documents, etc.) of 60,000 – 120,000 records/appeals at implementation.