Medicare:

Incomplete Plan to Transfer Appeals Workload from SSA to HHS Threatens Service to Appellants

GAO-05-45: Published: Oct 4, 2004. Publicly Released: Oct 4, 2004.

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The Medicare appeals process has been the subject of widespread concern in recent years because of the time it takes to resolve appeals of denied claims. Two federal agencies play a role in deciding appeals--the Department of Health and Human Services (HHS) and the Social Security Administration (SSA). Currently, neither agency manages and oversees the entire multilevel process. In the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Congress mandated that SSA transfer its responsibility for adjudicating Medicare appeals to HHS between July 1, 2005, and October 1, 2005. In addition, it directed the two agencies to develop a transfer plan addressing 13 specific elements related to the transfer. GAO's objective was to determine whether the plan is sufficient to ensure a smooth and timely transition.

Transferring the Medicare appeals workload from SSA to HHS requires careful preparation and the precise implementation of many interrelated items. The transfer is mandated to take place no later than October 1, 2005. SSA and HHS have stressed their commitment to ensuring a successful transfer of the administrative law judge (ALJ) level of the Medicare appeals process, and both agencies have emphasized that they are continuing to further develop details of the plan. Although the plan generally addresses each of the 13 elements mandated by MMA, it omits important details on how each element will be implemented. Furthermore, the plan overlooks the need for contingency provisions, which could prove to be essential, should critical tasks not be completed in a timely manner. GAO believes that this essential information is needed to facilitate a smooth and timely transfer. Its absence makes it unclear how the transfer plan will be implemented and threatens to compromise service to appellants.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should prepare a detailed project plan to include interim and final milestones, individuals or groups responsible for completing key elements essential to the transfer, and contingency plans.

    Agency Affected: Social Security Administration

    Status: Closed - Not Implemented

    Comments: HHS and SSA did not update the jointly prepared transfer plan, incorporating GAO's recommendations. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in HHS revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should prepare a detailed project plan to include interim and final milestones, individuals or groups responsible for completing key elements essential to the transfer, and contingency plans.

    Agency Affected: Social Security Administration

    Status: Closed - Not Implemented

    Comments: HHS and SSA did not update the jointly prepared transfer plan, incorporating GAO's recommendations. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in HHS revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should validate data and perform analyses to support decisions regarding key elements, such as workload, staffing needs, and costs.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Not Implemented

    Comments: It is unclear the extent to which the agencies validated the data used for making decisions about workload, staffing, and office locations. However, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. The transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should validate data and perform analyses to support decisions regarding key elements, such as workload, staffing needs, and costs.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Not Implemented

    Comments: It is unclear the extent to which the agencies validated the data used for making decisions about workload, staffing, and office locations. However, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. The transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should outline a strategy that addresses the possible need for two separate processing systems at HHS--one for appeals that follows the current processing practices and one that complies with BIPA's time frames and other requirements--in the event that the BIPA provisions establishing the QICs are not implemented as scheduled.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Not Implemented

    Comments: Although HHS has addressed the need to establish two separate processing systems, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should outline a strategy that addresses the possible need for two separate processing systems at HHS--one for appeals that follows the current processing practices and one that complies with BIPA's time frames and other requirements--in the event that the BIPA provisions establishing the QICs are not implemented as scheduled.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Not Implemented

    Comments: Although HHS has addressed the need to establish two separate processing systems, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should identify where staff and hearing facilities--including videoconference equipment--are needed as well as opportunities to share staff and office space.

    Agency Affected: Social Security Administration

    Status: Closed - Not Implemented

    Comments: Although HHS has identified where staff, hearing facilities, and videoconference equipment would be located, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should identify where staff and hearing facilities--including videoconference equipment--are needed as well as opportunities to share staff and office space.

    Agency Affected: Social Security Administration

    Status: Closed - Not Implemented

    Comments: Although HHS has identified where staff, hearing facilities, and videoconference equipment would be located, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should develop an approach to ensure that ALJs and support staff with Medicare expertise can be hired, and that all staff are adequately trained to process and adjudicate Medicare appeals.

    Agency Affected: Social Security Administration

    Status: Closed - Not Implemented

    Comments: Although HHS has developed a hiring and training plan, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should develop an approach to ensure that ALJs and support staff with Medicare expertise can be hired, and that all staff are adequately trained to process and adjudicate Medicare appeals.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Not Implemented

    Comments: Although HHS has developed a hiring and training plan, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should define the relationship of HHS's ALJ unit to the other organizations within the department, and identify safeguards that will be established to ensure decisional independence.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Not Implemented

    Comments: Although HHS has announced that it will locate HHS' ALJ unit within the Office of the Secretary, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. In addition, HHS has not specified safeguards that will be taken to ensure decisional independence. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

    Recommendation: To help ensure a smooth and timely transition of the Medicare appeals workload from SSA to HHS, the Secretary of HHS and the Commissioner of SSA should take steps to complete a substantive and detailed transfer plan. Specifically, the Secretary and Commissioner should define the relationship of HHS's ALJ unit to the other organizations within the department, and identify safeguards that will be established to ensure decisional independence.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Not Implemented

    Comments: Although HHS has announced that it will locate HHS' ALJ unit within the Office of the Secretary, HHS and SSA did not adhere to GAO's recommendations to incorporate this strategy in an updated and more detailed transfer plan. In addition, HHS has not specified safeguards that will be taken to ensure decisional independence. However, the transfer of the appeals function from SSA to HHS began on July 1, 2005, as scheduled. At this stage, there is no point in revising the transfer plan.

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