Wednesday, September 3, 2014

OMHA Announces Statistical Sampling Pilot to Reduce Medicare Appeals Backlog

Dianne De La Mare

The US Department of Health and Human Services, Office of Medicare Hearings and Appeals (OMHA) is implementing a Statistical Sampling Pilot (SSP) program, with the goal to reduce the significant Medicare Appeals backlog.

According to OMHA, the SSP allows the provider with large volumes of claims disputes at the administrative law judge (ALJ) appeals level to use statistical sampling to draw a random sample from the claims and extrapolate the sample’s results to all of the claims. Either the provider or OMHA may request statistical sampling. An OMHA employee, called a statistical sampling coordinator, will serve as the central point of contact for the provider.

An ALJ will conduct a pre-hearing conference to confirm consent for the statistical sampling. Then an order will be issued which becomes binding and the provider’s appeals are then combined into a single appeal that is assigned to a new ALJ for a hearing based on the sample selected by the OMHA statistical expert.

The ALJ will review the sample and make findings and issue a decision based on that sample. The decision on the sample will then be extrapolated to all of the remaining provider claims.

To obtain more information go to the OMHA fact sheet at http://www.hhs.gov/omha/statistical_sampling_fact_sheet.pdf.

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