Medicare: Incomplete Plan to Transfer Appeals Workload from SSA to HHS Threatens Service to Appellants
GAO-05-45
Published: Oct 04, 2004. Publicly Released: Oct 04, 2004.
Skip to Highlights
Highlights
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.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | 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. |
Closed – Not Implemented
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.
|
| Social Security Administration | 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. |
Closed – Not Implemented
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.
|
| Department of Health and Human Services | 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. |
Closed – Not Implemented
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.
|
| Social Security Administration | 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. |
Closed – Not Implemented
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.
|
| Department of Health and Human Services | 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. |
Closed – Not Implemented
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.
|
| Social Security Administration | 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. |
Closed – Not Implemented
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.
|
| Department of Health and Human Services | 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. |
Closed – Not Implemented
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.
|
| Social Security Administration | 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. |
Closed – Not Implemented
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.
|
| Department of Health and Human Services | 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. |
Closed – Not Implemented
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.
|
| Social Security Administration | 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. |
Closed – Not Implemented
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.
|
| Department of Health and Human Services | 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. |
Closed – Not Implemented
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.
|
| Social Security Administration | 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. |
Closed – Not Implemented
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.
|
Full Report
Office of Public Affairs
Topics
Administrative law judgesAppealsAppeals processClaims adjudicatorsClaims processingHealth care programsHealth insuranceInsurance claimsInteragency relationsMedical expense claimsMedicarePlanning