Medicare Appeals to an ALJ: How Long Will I Wait?
Medicare established the Office of Medicare Hearings and Appeals to address disputes between providers and the Centers for Medicare & Medicaid Services. OMHA is the department that employs Administrative Law Judges to hear cases following the Reconsideration level of appeal. There is a commonly-held perception that ALJ wait times are so long that appealing to that level of review has no value. In this post, we'll share current information so that you can make informed decisions about appealing to an ALJ moving forward.
What You Need to Know
Between fiscal years 2012 and 2017, the number of requests for hearings filed with the OMHA increased significantly, outpacing its adjudication capacity. This surge led to substantial delays for most appellants. For instance, the average number of days for an appeal to be heard escalated from 94.9 days in FY09 to an alarming 1,430.1 days - that's nearly 4 years! - in FY20.
To address these delays, OMHA hired more ALJ's and opened new field offices. The effects have been dramatic: the average number of days for an appeal to be heard in financial year 2024 is down to 71 days.
What this Means for You
If you have an appeal that is denied at the Reconsideration level of review, you will not have to wait for years to get in front of an ALJ. While that has been true in the past, current delays are just over two months.
In addition, if you have a patient who is organized and capable of advocating effectively on their own behalf, patient-filed ALJ appeals get fast-tracked in the OMHA system, meaning that the ALJ will issue a hearing date even earlier. Be aware, however, that while you can and should prep patients for a hearing if they initiate the appeal, ALJ's expect that the patient will actually be the primary person speaking at the hearing. We are aware of historical instances where suppliers had the patient file the appeal to get a faster hearing date, but then the patient largely deferred to the supplier during the hearing. ALJ's view this as an abuse of the appeals process and it could affect the possibility of a positive appeal outcome. It is appropriate, though, for the patient to include a prosthetist, orthotist, physician, PT, etc., as witnesses if they have information relevant to the appeal.
For more information about OMHA, time to a hearing date, and appeals outcomes, visit the OMHA website.