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Post by trekker on Oct 22, 2013 8:28:40 GMT -5
OMHA has been mentioned in a couple of different threads and I believe that in the next year or two, we may see an expansion of the number of ALJ's assigned to hear these cases. As some of you know, OHA (now ODAR) used to hear Medicare appeals. A few years ago, a new appeals process was established to hear these cases. There are a couple of different tracks involved: one for traditional Medicare and one for Medicare Advantage. Ultimately, once a claimant gets past the first two levels of appeals (which can take almost a year - there is an expedited track for Part D and hospital discharges), the case will end up at OMHA. The interesting issue for those of us who land on the register and then ultimately on a cert is that OMHA is experiencing significant delays because of an increase in appeals. It is supposed to take 90 days from the date a claimant files a request for hearing to him/her receive a decision. It is now taking 8-12 weeks for OMHA to schedule hearings. There may be a number of reasons why this is happening including more denial notices actually getting to the Medicare beneficiary and most of the denials being upheld by the contractor (Maximus) for appeals at Step 1 & 2. The hearings are becoming more adversarial as well as health plans, which receive capitated rate payments to provide care for beneficiaries in HMO's, have attorneys represent them at the hearings. There are only four hearings offices (Irvine CA, Arlington VA, Miami FL, & Cleveland OH) and a limited number of ALJ's as has been noted by others on this board (funky in particular). The hearings are generally video-teleconferencing. The only cert for OMHA that I could find in a search I did on this board was in 2010 and I am not sure if there have been any hires since then. The Chief ALJ and Deputy Chief ALJ of OMHA came from ODAR and it is my understanding that most of the OMHA ALJ's also came from there.
The reason for this thread is to bring attention to this particular hearing office and my suspicion (that is all it is) that there will be an increase in the number of ALJ's needed for OMHA. It is bad enough to wait more than a year to get your disability case heard by an ALJ but most people don't like waiting to get their health care or having to pay up front for care that they and their provider believe is medically necessary. (Please note: there is a $140 in controversy requirement for appeals before OMHA.) For those of you who like the adversarial approach to administrative hearings, you will probably find it here. But of course, you will also find that in general, neither side understands the process well enough yet and it is still a youngster working out the kinks.
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Post by ssaogc on Oct 22, 2013 8:43:04 GMT -5
The reason for this thread is to bring attention to this particular hearing office and my suspicion (that is all it is) that there will be an increase in the number of ALJ's needed for OMHA. It is bad enough to wait more than a year to get your disability case heard by an ALJ but most people don't like waiting to get their health care or having to pay up front for care that they and their provider believe is medically necessary. (Please note: there is a $140 in controversy requirement for appeals before OMHA.) For those of you who like the adversarial approach to administrative hearings, you will probably find it here. But of course, you will also find that in general, neither side understands the process well enough yet and it is still a youngster working out the kinks. I hope your predictions are correct. I would rather work at OMHA than SSA but beggars cannot be too picky. Keep in mind that they only have four locations (Miami, Irvine, Alexandria(Arlington?) and Ohio (cleveland I think) and they have to be on your GAL to be considered. |
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Post by Gaidin on Oct 22, 2013 8:52:15 GMT -5
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Post by bartleby on Oct 22, 2013 8:59:56 GMT -5
IIRC, the 90 day guideline for decisions could be waived by counsel for the claimant and I would note that not many reps would deny the waiver as it might irritate the Judge. Number 2, the cases I worked on had already been paid and were in dispute as to whether the services were necessary and if they were not, the claimant, ie, nursing home or medical facility would have to re-imburse the Government for the "overpaid" services. Some fraud was discovered along with the overpayments. soem fo the time you will have a corporate entity as yoru claimant and not an individual. As such, you may look at numerous claimants all with the same service. A Judge may spend a lot of time determining the size of ulcers developing from bed sores or the need for services such as air beds and/or wet to dry dressings for said bed sores or as such as PT for a comatose patient along with speech therapist to teach said comatose patient how to swallow. Be careful what you wish for. At least our claimant's come to a hearing and have various problems.. Medicare Judges have attorneys working with them and the attorneys will develop the case and narrow the issues and write the decision. Normally the Judge sits in his office and has IVT hearings or telephone hearings.. Maybe not as much personal satisfaction??
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Post by ssaogc on Oct 22, 2013 9:03:23 GMT -5
Do they have the same production requirements?
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Post by epic0ego on Oct 22, 2013 9:05:41 GMT -5
good info, Trekker. thanks for posting. In Arlington, Va, at least, the scores that were interviewed and ultimately hired, were in the 70s. It should be mentioned that several agencies tap into the OPM ALJ register in the rare instances when they hire. But many hire independently by putting out an announcement that requires previous ALJ experience. A large number of SSA ALJs routinely apply for those positions.
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Post by goodoleboy47 on Oct 22, 2013 9:57:12 GMT -5
All paper cases. No electronic files. Backlog growing like a tick on a deer. Hearings held at an office desk except big box cases (3-4 yearly per judge). Funding problems. Affordable Care Act impact unknown. Not a pretty picture for wantabes. Yes there are quotas. Not the same type of operation as it was when SSA held the hearings. They were fun to do and a nice break from regular disability cases back then.
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Post by zebra51 on Oct 22, 2013 10:40:19 GMT -5
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Post by trekker on Oct 22, 2013 11:23:40 GMT -5
I know of at least one state that will have a state exchange as well as Medicaid expansion and appeals will be run through their state hearing office. (It is unclear whether or not appeals related to subsidies will go through the state appeals process because that is an IRS responsibility.) We were told that the state DoJ would be representing the exchange in that state. Not sure about other states since not all states will have their own exchange nor will they have Medicaid expansion. And please remember that the vast majority of individuals on Medicare are prohibited from purchasing insurance through the exchanges. There are two limited exceptions: individuals who are eligible for Medicare ESRD and those who have Medicare Part A because they pay the premium for it.
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Post by lildavey on Oct 22, 2013 12:28:44 GMT -5
I know of at least one state that will have a state exchange as well as Medicaid expansion and appeals will be run through their state hearing office. (It is unclear whether or not appeals related to subsidies will go through the state appeals process because that is an IRS responsibility.) We were told that the state DoJ would be representing the exchange in that state. Not sure about other states since not all states will have their own exchange nor will they have Medicaid expansion. And please remember that the vast majority of individuals on Medicare are prohibited from purchasing insurance through the exchanges. There are two limited exceptions: individuals who are eligible for Medicare ESRD and those who have Medicare Part A because they pay the premium for it. In our state (New Mexico) medicaid appeals will be handled by the state ALJs of the Fair Hearings Bureau. The state will be represented by lawyers from the Human Services Department's Office of General Counsel, but only if the Claimant has an attorney. |
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