Lets start

Introducing Introducing Administrative Law Judge Irwin SchroederManaging Judge of Mid-Atlantic Hearing OfficeManaging Judge of Mid Atlantic Hearing OfficeOffice of Medicare Hearings and AppealsArlington, Virginiag , g

PATH TO ALJ HEARINGPATH TO ALJ HEARING

Federal CourtMAC (HHS level)ALJ Hearing (OMHA)

Reconsideration (QIC)R d t i ti (FI)Redetermination (FI)

Initial Determination (FI)

What is different at ALJ level

Difference in Decision MakerDifference in Decision MakerA. First federal employeeB. First experienced judgeB. First experienced judgeC. First unrelated to CMS

Difference in RecordDifference in RecordA. First oral hearingB. First opportunity to confront. s oppo u y o co oC. First independent expert

OMHA Organizationg

Average case timeg

ALJ Hearing Historyg y

140.8

159.1

ns

per

Da

y

FY10

FY09

117.0

119.4

Dis

posi

tion FY08

FY07

131 3

146.1

174.0

ts p

er

Da

y

FY10

FY09

92.7

131.3

Re

ceip

t

FY08

FY07

0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0 180.0

What to Expect at ALJ Levelp

1. A decision in 90 days or less –1. A decision in 90 days or less Unless you need more time to prepare

2 Ability to present expert testimony on 2. Ability to present expert testimony on A. Medical practices and conceptsB. Business practices and consequencesB. Business practices and consequencesC. Statistical concepts and theories

3 Time to argue any relevant facts and law3. Time to argue any relevant facts and law

What to Expect at ALJ Levelp

4. Varied hearing formats at your option4. Varied hearing formats at your optionA. Telephone – most favorB. Video Teleconference – at our expenseB. Video Teleconference at our expenseC. In person – at hearing office or otherD. Mixed format – e.g. Counsel in person witness on the g ptelephone

What is in your request?y q

1. Information required by the regulation1. Information required by the regulation42 CFR 405.1014

2. Concise theory of why you should be paid2. Concise theory of why you should be paid3. List of few documents you must have4 List of witnesses you will offer4. List of witnesses you will offer

Value of their testimonyDocuments they needDocuments they need

Where are CMS and contractors

1. Participation by CMS, QIC and other contractors 1. Participation by CMS, QIC and other contractors is optional2. CMS has a unit in Baltimore which monitors 2. CMS has a unit in Baltimore which monitors appeals3. QIC and CMS can petition MAC for review of 3. QIC and CMS can petition MAC for review of ALJ decisions

Purpose for ALJ Hearingp g

1. Arguments of Policy and Legal Issues1. Arguments of Policy and Legal Issues2. Clarification of Record Documents

Illegible Illegible Professional vocabulary and usageSequence of eventsSequence of events

3. Receive evidence not previously submitted for good causegood cause4. Drama and Catharsis

Submission of Evidence

Initial Determination – All ElectronicInitial Determination All ElectronicRedetermination – First look at LCD NeedReconsideration Last easy placeReconsideration – Last easy placeALJ Hearing – Oral Explanation and Expert Testimony without showing good causeTestimony without showing good cause

Preparation for Hearingp g

How common is this claim type?How common is this claim type?How medical is this claim?How legalistic is this claim?How legalistic is this claim?How mechanical is this claim?H i i hi l i ?How expensive is this claim?

Rules of Decision

1. Social Security Act and amendments1. Social Security Act and amendments2. Regulations at 42 CFR 400 and following3 NCDs issued by CMS through public process and 3. NCDs issued by CMS through public process and opportunity to appeal4 LCDs issued by Carriers with notice to the public4. LCDs issued by Carriers with notice to the public5. Interpretations of the above

What is not for ALJ Hearingg

1. Any decision other than an initial determination1. Any decision other than an initial determination2. A challenge to a payment schedule3 A challenge to the requirements of an NCD or an 3. A challenge to the requirements of an NCD or an LCD4 A challenge to the decision to extrapolate from a 4. A challenge to the decision to extrapolate from a statistical sample5 A challenge to the decision to reopen5. A challenge to the decision to reopen