__-_ - -,_...“-,_.l---- -.-I_lJllit,wi Statw ~-(ktrt~ral Accorrnt,ing Of’f’iw 13rief’ing Report to the Chairman, GAO Commit,t,ee on Appropriations, TJ.S. Senat,e MEDICARE PART A REIMBURSEMENTS Processing of Appeals Is Slow United States General Accounting Office Washington, DC. 20648 Human Resources Division B-233662 February 9,199O The Honorable Robert C. Byrd Chairman, Committee on Appropriations United States Senate Dear Mr. Chairman: This study of the adequacy of staffing levels at the Provider Reimburse- ment Review Board (PRRB) was prepared in response to a directive in Senate Report No. 100-399. That report, dated June 23,1988, concerns the fiscal year 1989 appropriations bill for the Department of Health and Human Services (HHS). A five-member, quasijudicial body, PRRB was established under the hos- pital insurance portion (Part A) of the Medicare program. PRRB conducts hearings and issues decisions on appeals by hospitals, skilled nursing facilities, and home health agencies on the amount of reimbursement Medicare allowed for beneficiaries’ care. As agreed with Committee staff, we addressed specific concerns about PRRB, including (1) whether the Health Care Financing Administration (IICFA), which administers Medicare, has impaired PRRB'S ability to pro- cess cases by limiting staff allocations and (2) its timeliness in process- / ing cases. In conducting this study, we reviewed statutes, regulations, and legisla- Methodology tive history pertaining to the relationship of PRRB to HHS and HCFA. In addition to reviewing data on PRRB'S staffing levels, we met with HCFA officials to discuss the agency’s rationale for PRRB'S current staff alloca- tions We also interviewed PRRB board members, paralegal specialists, and legal technicians about staffing issues. To determine case disposition, we analyzed data from PRRB'S automated and manual data systems as of February 1989. The manual system included information on about 1,600 cases, most filed prior to the November 1987 implementation of the automated system. About 2,499 cases are tracked in the automated system. Page 1 GAO/HRD-99-23BR Medicare Part A Appeals Process Slow 8’ /. B-233662 In summary, we found that Results in Brief l PRRB and HCFA are functioning in a manner consistent with their legisla- tively prescribed roles for administering Part A of the Medicare pro- gram. While PRRB’S ability to process cases has been impaired by HCFA’S allocation of resources, we found no evidence that HCFA set the Board’s staffing levels or denied PRRB’S requests for additional staff with the intent of deliberately impairing its effectiveness. HCFA has attempted to support the Board by providing contract funds for data processing support. . PRRB’S reported inventory, about 4,000 cases as of February 1989, was not an accurate indicator of its workload. Because of staffing shortages, PRRB had taken no action since November 1987 or earlier on most of the cases it was monitoring in its manual data system. Of the approximately 1,080 cases filed in the first 5 months of fiscal year 1989, PRRB had not tracked two-thirds because it had not entered them in the inventory. In addition, some sampled cases in the manual system were inactive, dupli- cated cases in the automated system, or could not be verified because files were missing. . PRRB’S processing of cases was slow. Of about 3,370 cases, most were concentrated in the first 2 steps of PRRB’S 17-step appellate process. Fur- ther, cases in PRRB’S automated data system’ took longer to move through the early steps of the appellate process than the time allowed. (See app. I for a description of the 17-step process and app. II for sup- plemental information on the disposition of cases.) Although the number of cases resolved through decisions and dismissals and removed from inventory had increased steadily between fiscal years 1975 and 1987, it decreased between fiscal years 1987 and 1988. During this time, PRRB’S staff decreased from 27 to its ceiling level of 24, and two employees who were processing cases were transferred to supervisory positions. Addi- tionally, responsibility for making initial jurisdictional determinations was shifted from paralegal specialists (GS14s) to legal technicians (GS-6s). Finally, the actual workload of PRRB legal technicians greatly exceeded that recommended by a HCFA management study. . In its annual budget appropriation request, HHS combines PRRB’S and HCFA’S staff and monetary needs but does not identify PRRB separately. We found no evidence that HCFA, in setting the Board’s staffing levels Conclusions and denying PRRB’S requests for additional staff, deliberately intended to ” ’L3ecause of the difficulty in extracting information from the manual data system,we analyzed processingtime only for 2,289casesin the automateddata system. Page 2 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow B-233662 impede its effectiveness. PRRB is but one of several components that must compete for limited HCFA resources. Nevertheless, HCFA'S allocation of resources did impair PRRB'S ability to process cases. For PRRB and HCFA to determine accurately the appropriate number of staff E'RRRneeds to process cases in a timely manner is difficult. PRRB has no accurate count of the cases in inventory and may not have realistic time frames for each step in the process. HHS'S current format for budget submissions does not provide the information the Committee on Appro- priations needs to directly monitor the resources requested for PRRB'S operations. We recommend that the Secretary of HHS direct HCFA and PRRB to work Recjommendationsto together to establish an accurate case inventory, determine the number the1Secretary of HHS of staff needed to process cases in a timely manner, and reevaluate time frames for each step in the process. I If the Committee on Appropriations wishes to directly monitor the level Matter for of resources requested for PRRB'S operations, it may want to consider Consideration directing that PRRB be identified separately in the HHS appropriation request. In a letter of November 29, 1989, commenting on our draft report, HHS Agency Comments indicated that it was encouraged and pleased by our findings that MCFA and ~RRB are functioning in a manner consistent with their legislatively prescribed roles and that HCFA had not attempted to interfere with the functioning of the Board by restricting staff allocations. HHS also stated that our findings accurately assessed the status of PRRB'S cases during the time of our review (October 1988 through February 1989). Hut IIIIS concluded that changes PRRB has made, or is in the process of making, “have for the most part rendered these findings moot.” While IIIIS'S comments indicate that PRRB has already responded to the portion of our recommendation concerning the need to assess staff job skills, HHS provided very little information that allowed us to assess the nature or extent of PRRB'S actions regarding the remaining portions of our recom- mendation. Appendix III contains the full text of HHS'S comments. Page 3 GAO/HRD-90.23BRMedicare Part A Appeals ProcessSlow ! I I ,“-~‘~~‘-“‘.- ..-. - . ..-- ~- I R-233662 W h ile the operational improvements PRRB has made thus far are impor- tant, alone they have not corrected the problems we identified, thus ren- dering our recommendations “moot.” W e continue to recommend that I'RRD establish an accurate case inventory, determine the number of staff needed to process cases, and reevaluate tim e frames for each step in its process. As arranged with the Committee staff, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days from the date of this letter. At that time, we will send copies to the Secretary of HHS, the Administrator of HCFA, the Chairman of I’RRR, and other interested parties. Please contact m e at 275-1655 if you or your staff have any questions concerning this briefing report. Other major contributors to the report are listed in appendix IV. Sincerely yours, Linda G. Morra Director, Intergovernmental and Management Issues Page 4 GAO/HRD-90.23BR Medicare Part A Appeals Process Slow I .., .I_. _. ..“. . ..- -- Page 5 G A O / H R D - 9 0 - 2 3 B R M e d i c a r e Part A A p p e a l s Procrss S l o w !- 1 1 COntents Leiter 1 Section 1 8 Introduction Objectives 8 Scope and Methodology 9 Background-Provider Reimbursement Review Board 11 Hearing Process an Adversarial Proceeding 13 Staffing: HCFA Provides Support Staff 14 Organizational Composition 16 Section 2 19 Nature of PRRB’s Relationship to HCFA and HHS TQnelinessof Case Reported Inventory Increasing Reported Inventory Inaccurate 21 23 Processing Case Inventory Concentrated Early in Appellate Process 25 Cases Stayed in Early Steps Long Periods of Time 27 PRRB’s Case Output Down Over S-Year Period 29 Several Factors Contribute to Drop in Case Output 31 Section 4 33 Conclusions, Conclusions Recommendation to the Secretary of HHS 33 33 Recom m endation, Matter for Consideration 33 Matter for Agency Comments and Our Evaluation 33 Consideration, and Agency Com m ents Appendixes Appendix I: Description of the 17 Major Processing Steps 36 in PRRB’s Appellate Process Appendix II: Supplemental Case Information 39 Appendix III: Comments From the Department of Health 40 and Human Services Appendix IV: Major Contributors to This Report 45 Page 6 GAO/HRDSO-23BR Medicare Part A Appeals Process Slow Contents Tables Table II. 1: Average Number of Days Cases Were in Each 39 Step of the Appellate Process (As of Feb. 2, 1989) Table 11.2:Projected Disposition of Cases in PRRB’s 39 Manual Data System (As of Feb. 17,1989) Table 11.3:Projected Distribution of “Active” Cases From 39 PRRB’s Manual Data System by Step in the Appellate I Process (As of Feb. 17, 1989) Figbres Figure 1.1: Objectives 8 Figure 1.2: Methodology 9 Figure 1.3: Background-PRRB 11 Figure 1.4: Hearing Process 13 Figure 1.6: Staffing 15 Figure 1.6: Organizational Composition 16 Figure 2.1: Nature of PRRB’s Relationship to HCFA and 19 HHS Figure 3.1: Reported Inventory Is Increasing 22 Figure 3.2: Reported Inventory Is Not an Accurate 23 Indicator of Workload Figure 3.3: Cases Concentrated in Early Steps of 26 Appellate Process Figure 3.4: Cases Were in Early Steps Long Periods of 28 Time Figure 3.5: PRRB’s Case Output Has Decreased 30 Figure 3.6: Decline in Case Output Due to Several Factors 31 Abbreviations GAO General Accounting Office HCFA Health Care Financing Administration HHS Department of Health and Human Services PRRB Provider Reimbursement Review Board Page 7 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow ! Sectiion 1 ~ titroduction Fiaude 1.1: (G- Objectives l Has HCFA’s relationship with PRRB impaired PRRB’s effectiveness in processing cases? l How timely is PRRB in processing cases? Concerned about recent Provider Reimbursement Review Board staffing Objectives reductions, the Committee on Appropriations asked that we report on whether the Health Care Financing Administration was unwilling to provide PRRB with the staff it needs to function effectively. As a result of this request and subsequent discussions with Committee staff, we agreed to determine . whether WXA'S relationship with PHRB impaired PRRB'S effectiveness in processing cases by limiting staff allocations and l how timely PRRH has been in processing cases. Page 8 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Section 1 Introduction Figui re ~0 Methodology 0 Review relationship between HCFA and PRRB l Analyze authorized and actual staffing levels l Analyze cases as of February 1989 l Interview PRRB staff In its June 23, 1988, report directing our study, the Committee on Scope and Appropriations expressed concern over the potential appearance of a Methodology conflict of interest in HCFA'S unwillingness to allow the Board adequate staff. We did not address the conflict of interest question because the term generally applies, not to agencies, but to individuals whose per- sonal interests conflict with the responsibilities of their positions. To address the Committee’s concerns, however, we sought to determine whether HCFA impaired PRRB'S effectiveness in processing cases by limit- ing its staff allocations. Page 9 GAO/HRD-90s23BR Medicare Part A Appeals Process Slow Section 1 Introduction In accomplishing this objective, we reviewed statutes, regulations, and legislative history pertaining to the relationship between PRRB, the Department of Health and Human Services, and HCFA. In addition to ana- lyzing I'RRB'S actual and authorized staffing levels, we discussed the rationale for PRRB'S current staff levels with HCFA officials. We analyzed the distribution of about 3,370 cases in PRRB'S 17-step appellate process. This number excluded the cases we determined were inactive, duplicative, missing supporting documentation, or in suspen- sion. In addition, we excluded 111 cases that PRRB indicated were being considered for dismissal. PRRB uses both manual and, starting in Novem- ber 1987, automated data processing systems to monitor this disposition of cases. Our analysis included all cases in the automated system and a sample of 1,582 cases from the manual system as of February 1989. We sought to determine the distribution of the cases in the appellate process and the time taken to move through major steps of the process. This type of information was unavailable for about 1,600 cases in the manual system that were filed between fiscal years 1975 and 1988. Therefore, after reviewing a randomly drawn representative sample of 100 cases from the 1,582 that were filed between fiscal years 1980 and 1988, we pro- jected the results to the cases from which the sample was drawn. In addition, we reviewed the records for all 19 cases filed between fiscal years 1975 and 1979 that were still in the manual data system in Febru- ary 1989. We determined the number and type of staff responsible for processing cases at each major step in the appellate process. Using a structured interview guide, we interviewed PRRB board members, para- legal specialists, and legal technicians about staffing issues. Our review was performed between October 1988 and June 1989 in accordance with generally accepted government auditing standards. Page 10 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow sectIon 1 Introduction Figure 1.3: im I Background--PRRB l Established to review payment disputes under part A l Serves as an administrative appeals forum for providers l PRRB’s jurisdictional thresholds $lO,OOO for a single provider ~$50,000 for a group of of providers In 1972, the Congress authorized the establishment of PRRB to review Background- payment disputes under the hospital insurance portion (Part A) of the Provider Medicare program. A federal health insurance program authorized by Reimbursement title XVIII of the Social Security Act, Medicare helps most Americans age 65 and over and certain disabled individuals under 65 pay for their Review Board health care. Medicare Part A pays for services provided by hospitals, skilled nursing facilities, and home health agencies. In fiscal year 1988, v Part A covered about 32 million enrollees and paid benefits amounting to about $52.7 billion. Page 11 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow .“--+.--- -..-~. -.. .--- Section 1 Intruduction I’HHBprovides an administrative appeals forum for Part A providers dis- satisfied with intermediaries’ determinations of reimbursement amounts. Intermediaries are HCFA-contracted organizations that process Medicare claims and make payments to Part A providers. PRRH,which comprises five members, including a chairman, conducts hearings and issues decisions on providers’ appeals, For a single provider, the amount in controversy must be $10,000 or more for a year and, for a group of providers with a common question of fact or law, $50,000 or more. For claims not meeting these jurisdictional threshold amounts, providers may request reconsideration by the Medicare intermediary that initially reviewed the claim. Page 12 GAO/HRD-SO-23BR Medicare Part A Appeals Process Slow Section 1 Introduction Figure 1.4: JGGAQHearing Process l PRRB can affirm, modify, or reverse intermediaries’ initial cost decisions 0 HCFA can review PRRB decisions l Providers can appeal PRRB or HCFA decisions to the courts The parties to a I'RRB hearing are the provider and the intermediary that Hearing Process made the cost determination under appeal, or the provider and IKSA in an Adversarial situations where there is no contracted intermediary.’ PRRH'S hearing Proceeding process is an adversarial proceeding during which the parties involved can be represented by counsel, introduce and cross-examine witnesses, and challenge all matters applicable to the issues in controversy. At the conclusion of the hearing, PRRB affirms, modifies, or reverses the intermediary’s decision. In turn, the Secretary of HHS has delegated to ’IIWA has not actedas intermediary since 1982. Page 13 GAO/HRD-90-23BR Medicare Part A Appeals Prncess Slow Section 1 Introduction the IICFA Administrator the authority to affirm, modify, or reverse PRRB'S decision. The HCFA Administrator has redelegated this authority to the Deputy Administrator of HCFA. While the Administrator or Deputy Administrator may review a decision in response to a request from HCFA or a party to a Board’s decision, the determination to review a case is made solely at the discretion of the Administrator or Deputy Adminis- trator. A ruling by PRRB or HCFA that the intermediary’s determination of the amount due the provider is too low results in an additional payment to the provider from the Federal Hospital Insurance Fund. Providers dissatisfied with the decision of PRRB or HCFA can appeal the decision to the federal courts. DHRH'S board members are appointed by the Secretary of HHS to serve a Staiffing: HCFA term of 3 years. One member is required to be a certified public account- P&ides Support Staff ant, two must be representatives of providers, and all must be knowl- edgeable in the field of cost reimbursement. PRRB'S enabling legislation also provides that the Secretary of HHS make available the technical, sec- retarial, and other support the Board may require to fulfill its responsi- bility. While retaining the authority to appoint board members, the Secretary of IIHS has delegated responsibilities for supporting the Board to the HCFA Administrator. The annual HHS budget appropriation request does not identify PRRB'S staff and monetary needs separately but incor- porates them with HCFA'S. Page 14 GAO/HRD-SO-23BR Medicare Part A Appeals Process Slow .------+- Section 1 Introduction Figure 1.5: GA3 Staffing l Board members are appointed by the Secretary of HHS l Support staff are allocated by HCFA Y Page 16 GAO/HRD-fJOI3BR Medicare Part A Appeals Process Slow Section 1 Introduction Figurg 1.6: ~GA0 Organizational Composition Chairman Board \ \ \ ur~amza~iona~~y, kww nits two componems, one ror Jurisaicnon ana case Organizational management, the other for hearings and decisions (see fig. 1.6). Composition Page 16 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow - Section 1 Introduction Jurisdiction and Case The jurisdiction and case management component consists primarily of Management legal technicians (GS-6 and -7 employees) and paralegal specialists (GS-14 employees). The staff determine which cases the Board has juris- diction over and manage such cases until they are ready for a hearing, dismissed, or withdrawn. For example, the legal technicians in the juris- diction and case management component . receive incoming requests for hearings, identify the provider, and assign a case number and other required identification; . review cases to determine whether they have been properly filed and , assure that each case includes all required material; . solicit omitted information and respond to routine inquires from provid- ers and intermediaries; . analyze cases when it is clear that PHRB has jurisdiction and refer cases to a paralegal specialist when they cannot determine jurisdiction; and . request position papers from the providers and intermediaries on the issues to be adjudicated. The paralegal specialists provide advice to the Board and legal technicians on whether or not IWB has jurisdiction and develop complex jurisdictional issues on whether the Board can rule on a case and present them to the Board with recommendations on whether PIZKIIshould accept or reject it. Hearings and Decisions The hearings and decisions component is composed primarily of GS-14 paralegal specialists. This component manages cases from the time a hearing is scheduled until the decision has been issued. For example, hearings and decisions staff members . obtain agreements and stipulations from the providers and intermediaries prior to the hearing on the issues in dispute and the perti- nent facts; . prepare for each case a comprehensive summary that sets forth the essential facts, significant contentions, evidence, relevant law, and precedent; . attend and assist the Board at conferences and hearings; . participate, advise, and assist the Board in its deliberations in light of their personal knowledge and research of legislation, regulations, and Medicare principles of reimbursement; and . prepare, develop, and draft decisions for the Board’s review. Page 17 GAO/HRD-90.23BR Medicare Part A Appeals Process Slow Section 1 Introduction At the beginning of fiscal year 1989, PRRB had 23 staff members, includ- ing 4 board members, 9 jurisdiction and case management staff, and 6 hearings and decisions staff. The remaining four staff members included the Executive Director and administrative personnel. Y Page 18 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow - -_--.- Section 2 N@ureof PRRB’sRelationshipto HCFA and HHS Figure 2.1: ~m Nature of PRRB’s Relationship to HCFA and HHS l Relationship is consistent with their l&gislatively I prescribed roles l HCFA can impair PRRB’s operations by limiting staff l No evidence HCFA set staffing levels with the intent of impairing PRRB’s effectiveness In its June 23, 1988, report directing this study, the Committee on Appropriations expressed concern that by exercising control over PRRB'S resources, especially staffing levels, HCFA could impaired PRRB'S effec- tiveness in processing cases. While HCFA has impaired the functioning of the Board by limiting its staff allocations, we found no evidence that IICFA had acted deliberately to impair the Board’s effectiveness. For fiscal year 1988, HCFA, citing agency-wide reductions, denied PRRB'S request for additional staff to handle a larger than anticipated work- load. HCFA officials indicated that most components, including PRRB, had experienced decreases in their staffing levels. Since 1981, demands on Page 19 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Section 2 Nature of PRRB’s Relationship to HCFA and HHS the agency have increased substantially as a result of new legislative requirements and administrative initiatives. Because IICFA'S staff com- plement decreased 21 percent over the same period, most components have been forced to do more with less. Faced with staffing constraints, IICFA has attempted to support the Board through other means. For example, in fiscal year 1989, HCFA approved $230,000 in contract sup- port for the Board. At the time of our review, PRRR had used $80,000 of the funds for data processing support. PRRB and IICFA are functioning in a manner consistent with their legisla- tively prescribed roles for administering Part A of the Medicare pro- gram, our review indicates. Although the Secretary has delegated certain responsibilities to HCFA, including providing support staff to the Board, ultimately the Secretary of HHS is responsible for insuring that HCFA performs its delegated responsibilities in accordance with applica- ble law and regulations. IICFA has no direct monetary stake in the outcome of the Board’s cases. If PRRI~rules that a provider is due additional reimbursement, the money comes from the Federal Hospital Insurance Fund-not IICFA- appropriated funds. The Secretary also has delegated to the HCFA Administrator authority to review PRRR decisions. While PRRI~reaches its decisions independently, it functions as part of the administrative proc- ess within III& as does IICFA, for resolving provider disputes. Page 20 GAO/HRD-90.23BR Medicare Part A Appeals Process Slow Tbeliness of CaseProcessing Although the number of cases that PRRB resolved and removed from inventory through the issuance of decisions and dismissals increased steadily between fiscal years 1975 and 1987, it decreased between fiscal years 1987 and 1988. As of February 1989, cases were concen- trated in the early steps of the appellate process for periods of time that exceeded PRRB-established criteria. While no single factor explains these occurrences, several events occurring around the same time may have contributed. Between fiscal years 1975 (when PRRB began operations) and 1988, the Reported Inventory number of cases filed with PRRB increased from 107 to about 1,500 (see Increasing fig. 3.1). The number of cases filed peaked in 1986, then decreased in 1987, due largely to HCFA policies for handling malpractice cases. The number of cases in inventory at the end of each fiscal year also grew at a rapid pace. At the end of fiscal year 1975, only 81 cases were in inven- tory; by the end of fiscal year 1988, about 3,600 were. Page 2 1 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Section 3 Timeliness of Case Processing Figure 3.1: CYQDReported Inventory is Increasing 3530 am0 am0 aooo 1900 loo0 WQ 0 ,076 1878 wl7 1978 1979 IWO lQ81 1982 1983 1984 1989 1988 1987 1980 Fiscal Vow B End-al Year Invmtory mm.- Filed Note: Number of cases filed and end-of-year inventory levels for FY 1976 are based on a ISmonth period. Page 22 GAO/HRD-90.23BR Medicare Part A Appeals Process Slow Section 3 Timeliness of Case Processing Fiaute 3.2: ~w Reported Inventory is Not an Accurate Indicator of Workload l Some cases were not in inventory l Large number of cases may be inactive Reported Inventory was inaccurate. Some cases received in fiscal year 1989 had not been Inaccurate added to inventory, and PRRB officials were unsure whether a number of the cases in its inventory were still active. About 1,600 cases, filed between fiscal years 1975 and 1988, were being monitored in PRRB'S manual data system. Most were filed before the November 1987 implementation of the automated system, which con- tained information on the disposition of the remaining 2,400 cases. Page 23 GAO/HRD-90.23BR Medicare Part A Appeals Process Slow Section 3 Timeliness of Case Processing But PRRB'S inventory was understated by about 690 cases. Although some 1,080 cases were filed in the first 5 months of fiscal year 1989, only 390 had been added to inventory. At the time of our review, PRRB was in the process of contracting for data entry support to enter the new cases. According to PRRB officials, they lacked the number of staff necessary to perform this task in a timely manner. Of the approximately 1,600 cases in the manual system, 1,572 had had no activity since November 1987 or earlier. PRRB officials said they were unsure whether these cases were still active and lacked the staff neces- sary to follow up on their disposition. From our sample of the 1,582 cases in the manual system filed between fiscal years 1980 and 1988,’ we estimate that 16 percent (252) were inactive and should have been deleted from inventory. (See tables II.2 and II.3 for the projected dispo- sition of the fiscal years 1980-1988 cases.) For example, PRRB counted in inventory a case filed in 1980, even though the parties involved had resolved it in 1984. Another case, received in 1983, was counted in inventory even though a decision had been issued in 1986. In addition, An estimated 32 cases were duplicates of those in PRRB'S automated system. An estimated 206 cases could not be traced because files were missing. An estimated 16 cases were in suspension pending the outcome of court decisions. Of the 19 cases filed between fiscal years 1975 and 1979 that were still in the manual system in February 1989, 10 were inactive and should have been deleted from the inventory. Most were inactive because PRRB had issued a decision. For example, PRRB included in inventory a case filed in 1975, on which a decision had been issued in 1977. Of the remaining cases, five were missing all supporting documentation and four were active. ‘The samplingerror for theseprojectionsdo not exceed-+ 10 percentat the 95percent confidence interval. Page 24 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Section 3 Timeliness of Case Processing I'RRB'S inventory of cases was concentrated in the early (prehearing) Case Inventory stages of the 17-step appellate process, which begins with the receipt of Copcentrated Early in a request for hearing and ends with the issuance of a decision (see Aplpellate Process app. I). The distribution of the approximately 3,370 cases we analyzed (depicted in fig. 3.3) was as follows: . Three-quarters, or about 2,500 cases, were in steps 1 and 2, in which I'RRI3 staff document the receipt of a case and review case documenta- tion to determine if additional information is needed to determine jurisdiction. . About 22 percent, or 730 cases, were in steps 3-5, in which PRRR deter- mines its jurisdiction over a case and staff identify the issues underlying it. . Only 3 percent (112 cases) were in later stages of the appellate process, i.e., steps 6-17, during which PRRB conducts the hearing and writes and finalizes its decision. Of these, 37 cases were scheduled for a hearing, 1 decision was being drafted, and 9 draft decisions were being reviewed by board members. Page 25 GAO/HRD-9@23BR Medicare Part A Appeals Process Slow ____ .,i__- .._ - ----_I-. _ Section 3 Timeliness of Case Processing - Figure 3.3: GM Cases Concentrated in Early Steps of Appellate Process 1000 Numbw 01 Cases 1400 1200 1000 ooo ooo 400 zoo 0 Slopa In Adjudhtlon Pmcaaa El Cases ProJected from Manual System Cases In Automated System .- ._._ _“.-__- Note: Analysis IS based on 2,290 cases in the automated system and an estimated 1,076 cases pro- jected from the manual system. PRRB’s database does not include information on cases in steps 7 and 11 of the adjudication process. Step 4 was added to the adjudication process in Nov. 1988, and as of Feb. 1989, few appeals had reached this step. The sampling error for cases projected from the manual system does not exceed + 10 percent at the 95percent confidence interval. At least half of all cases are resolved prior to a hearing, PRRB officials have estimated. (See tables II.1 and II.3 for supplemental information on PRRB'S distribution of cases.) Page 26 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Section 3 Timeliness of Case Processing Most PRRB cases were in the early steps of the appellate process for long CasesStayed in Early periods of time, our analysis of the 2,289 cases?showed. (See fig. 3.4 and Stqps Long Periods of table II.1 for the average lengths of time cases remained in each step of The the process.) For example, for steps 1, 2,3, and 5,:’cases had been in each step an average of at least 200 days. In the later parts of the proc- ess, cases remained in a step for significantly shorter periods, For exam- ple, cases in steps 6-17 were in a step for an average of 4 to 89 days. Although PRRB has established time frames for moving cases through the early steps of the process, these criteria may not be realistic, given staff- ing levels and the volume of cases in PRRB’S inventory. ‘Becauseof the difficulty in extracting information from the manual data system,we analyzed processingtimes only for casesin the automateddata system. %cp 4 was addedto the adjudicationprocessin November1988.As of February 1989,few caseshad reachedthis step. Page 27 GAO/HRD-90.23BR Medicare Part A Appeals Process Slow Section 3 Timeliness of Case Processing Figure 3.4: w Cases Were In Early Steps Long Periods of Time 1 - 200 200 130 100 50 - 0 I Note, Analysis IS based on 2,289 cases in the automated system. PRRB’s database does not include lnformatlon on cases in steps 7 and 11 of the adjudication process. Step 4 was added to the adjudlca- tlon process in Nov 1988, and as of Feb. 1989, few cases had reached this step. The sampling error for cases projected from the manual system does not exceed + 10 percent at the 95percent confidence level For example, PHIUS allows 30 days from receipt of a case for identifica- tion of the documentation necessary to determine jurisdiction and request missing documentation (step 1). However, the 1,283 cases in this step had been there an average of 278 days. For step 2, PHKB’Scriteria is 30 days for providers to submit the docu- mentation requested in step 1 and 30 days from its receipt for PRRR staff to determine jurisdiction. For cases in this step, PRRB had not received Page 2R GAO/HRD-90-23BR Medicare Part A Appeals Process Slow - section 3 Timeliness of Case Processing documentation within the 30-day time frame nor, for cases with com- plete documentation, had PRRB adhered to its 30-day limit for determin- ing jurisdiction. While PRRR'S criteria would suggest that cases should remain in step 2 no longer than 60 days total, the 370 cases in step 2 had been there an average of 210 days. PRRI3had determined jurisdiction for 38 of the 59 cases in step 3. For the remaining 21 cases, I'RRB had scheduled hearings for 8 and held hearings for 13 to determine jurisdiction. On average, cases had been in step 3 for 212 days. For cases in step 5, PRKH requires that within 60 days both parties sub- mit documents showing their positions on the issues. For 225 of the 414 cases in this step, documentation had not been received from the pro- vider within the established time, the intermediary, or both. On average, these cases awaiting documentation had been in step 5 for 237 days. For the remaining 189 cases, documentation was completed but they had not progressed to the next step. They had been in this step an average of 232 days from the receipt of position papers, When cases reach this step, time extensions often are granted if the parties indicate that they are negotiating a settlement, according to PHHR staff. In terms of the numbers of decisions issued and cases dismissed, PRRB’s Case Output case output decreased between fiscal years 1987 and 1988. Previously, Down Over its case output had shown a steady increase, as figure 3.5 shows. For Z-Year Period example, between fiscal years 1975 and 1987 the numbers of decisions issued increased from 3 to 115 and cases dismissed from 23 to 1,197. However, between 1987 and 1988 the number of decisions the Board issued dropped 65 percent to 40-the lowest since 1975-and the number of cases it dismissed by 39 percent, to 734. Page 29 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Section 3 Timeliness of Case Processing Figure 3.5: W PRRB’s Case Output Has Decreased 1200 Number of Wmm loo0 800 503 400 200 0 ,975 1975 1Qi-f lQ75 lQ7Q 1880 lQ51 1QW 1983 1984 1QM 198(1 1057 1M5 Fiecal Yun - Dlemlsaals 1-11 Dedsions Note: The numbers of decisions and dismissals in FY 1976 are based on a 15.month period. Y Page 30 GAO/~-QO-23BR Medicare Part A Appeals Process Slow Section 3 Timeliness of Case Processing Figwe 3.6: ~G&l Decline in Case Output Due to Several Factors l Staff attrition and reassignment l Realignment of staff 0 Heavy workload While no single factor explains the decrease in case output, several fac- Seiveral Factors tors may have contributed to it. For example, the large number of deci- C&tribute to Drop in sions (some 25 on one issue-labor delivery room costs) and the record Case Output number of dismissals issued in 1987 somewhat inflated that year’s case output. A change in HCFA'S reimbursement policy for malpractice insur- ance costs led PRRB to dismiss a record number of cases for lack of jurisdiction. Recent staff attrition has made it difficult to perform their mission, PRHH i officials said, Between fiscal years 1987 and 1988, the number of staff decreased from 27 to its ceiling level of 24. A staff reorganization Page 31 GAO/HRD-QO-23BR Medicare Part A Appeals Process Slow Section3 Timeliness of Case Processing intended to improve the timeliness of case processing and provide addi- tional staff supervision also affected output. In the reorganization, implemented in February 1988, two staff previously responsible for processing cases were transferred to supervisory positions. Lacking the 29 staff authorizations needed to fully implement their reorganization plan, the officials said, they have been unable to keep cases moving in the early steps of the process when PRRR action is required or to follow up on requested information. Output of cases was further affected by the realignment of staff respon- sibilities, which occurred at the same time the complexity of the cases was increasing. For example, the number of times the full Board con- vened to settle jurisdictional matters increased between fiscal years 1987 and 1988 from 28 to 73-161 percent. PRRB'S legal technicians (GS-fis), who prior to the reorganization had provided clerical support for the Board, were made responsible for initial jurisdictional determina- tions. Their clerical functions had consisted largely of typing, they said, but also included answering phones and duplicating materials. Before the reorganization, the paralegal specialists (GS-14s) made the jurisdic- tional determinations. Case processing has been impaired because there are not enough staff to manage cases in the early steps. A HCFA management study indicates that the appropriate size of a technician’s workload is about 220 cases. However, when we interviewed the three technicians, each was respon- sible for about 800 cases. Cases managed by the three technicians were in the initial steps of the appellate process significantly longer than the allowed time. Although I'RRB began fiscal year 1989 with five technicians, two- whose combined workload was about 1,230 cases-resigned. The super- visory legal technician, who normally is not directly involved in process- ing cases, stated that she handles all inquiries pertaining to these cases, as they have not been reassigned. The paralegal specialists in this com- ponent, who handle problem cases referred to them by the legal techni- cians, also said they had large case loads. The five GS-14 paralegal specialists in the hearings and decisions com- ponent, who depend on the output of technicians and staff in the juris- diction and case management component for cases, had a combined work load of 112 cases. Cases managed by these paralegal specialists were remaining in steps 6 through 17 for significantly shorter periods of time than those managed by staff in the jurisdiction and case manage- ment component. The latter are receiving fewer and fewer cases to pro- cess through to the hearing and decision steps. Page 32 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Section 4 Conclusions,Recommendation,Ma-r for Consideration,and Agency Comments No single factor explains the long time PRRB takes to process cases or the Codclusions recent drop in case output, but a lack of staff is one cause. Although IICFA has denied PRRB'S requests for additional staff, it did not do so with the intent of impairing PRRB'S effectiveness. While HCFA'S staff comple- ment has decreased, demands on the agency have increased, forcing it to do more with less. Thus, HCFA'S apparent unwillingness to provide the Board with staff is related to the allocation of scarce resources among competing demands. PRRB and HCFA have not established an accurate case inventory or assessed the number of staff needed, and may not have realistic time frames for each step in the process. Thus, it is difficult for them to determine the proper number of staff necessary to effectively operate the Board. The Committee on Appropriations does not receive routinely the infor- mation needed to monitor the resources provided PRRB because HHS' annual budget appropriations request does not identify PRRB'S monetary needs separately from that of HCFA'S. We recommend that the Secretary of HHS direct that HCFA and PRRB work Recommendation to together to establish an accurate case inventory, determine the number thel’secretary of HHS of staff needed to process cases, and reevaluate time frames for each step in the process. Matter for of resources requested for PRRB'S operations, it may want to consider Consideration directing that PRRB be identified separately in the HHS appropriation request. In its November 29, 1989, letter commenting on our draft report, HHS Agency Comments and indicated that it was encouraged and pleased by our findings that HCFA Our Evaluation and PRRB are functioning in a manner consistent with their legislatively prescribed roles and that HCFA had not attempted to interfere with the functioning of the Board by restricting staff allocations. It also stated that our findings accurately assessed the status of PRRB'S cases during the time of our review from October 1988 through February 1989. Page 33 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Section 4 Conclusions, Recommendation, Matter for Consideration, and Agency Comments HHS concluded, however, that changes PRRB has made, or is in the process of making, “have for the most part rendered these findings moot.” These changes include . restructuring PRRB'S appellate process to give providers and intermediaries more responsibility for determining jurisdiction and pre- paring cases for hearing, eliminating steps 2 and 3 of the process, and adjusting time frames; . recruiting lawyers or legally trained analysts, and l hiring a contractor to enter and update cases in its automated data system. HHS indicated that PRRB has already responded to the portion of our rec- ommendation concerning the need to assess staff job skills by working with HCFA to establish new staff positions, which have resulted in the recruitment of more highly trained and skilled employees. HHS reported that these changes already have increased the Board’s overall effi- ciency. We have revised the recommendation contained in this report to reflect PRRB'S progress in this area. However, HHS provided little infor- mation that allowed us to assess the nature or extent of PRRB'S actions regarding the remaining portions of our recommendation. For example, although HHS indicated that steps 2 and 3 of PRRB'S process have been eliminated and previously established time frames no longer apply, it provided little information to show that time frames for other steps experiencing delays had been reevaluated. HHS'S letter noted that significantly more decisions were issued during fiscal year 1989 than during fiscal year 1988 and that efforts are underway to determine the status of older cases. But HHS provided no information that would allow us to evaluate whether PRRB has established an accurate inventory as we recommended. Furthermore, HHS provided no response to our recommen- dation that HCFA and PRRB work together to define the number of staff needed to process cases in a timely manner. The changes made thus far are important improvements to PRRB'S proc- ess and could help to reduce case inventory levels and improve case management. We do not believe, however, that these changes alone can be presumed to have automatically corrected the problems we identi- fied, thus rendering our recommendations “moot.” As HHS acknowl- edges, PRRB will not be able to assess the effectiveness of its revised appellate procedures until it has operated under the new process for a period of time. Furthermore, the information contained in HHS'S letter does not respond to major portions of our recommendation. Thus, we Page 34 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Section 4 Conclusions, Recommendation, Matter for Consideration, and Agency Comments continue to recommend that PRRB establish an accurate case inventory, determine the number of staff needed to process cases, and reevaluate time frames for each step in its process. Page 36 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow D&miption of the 17 Major ProcessingSteps in PRRB’sAppellate Process A mail technician reviews the hearing request to determine the case step 1. type (i.e., individual or group). The supervisory legal technician assigns Ac’knowledgement and the request to a legal technician, who sends a letter to the provider and intermediary acknowledging PRRB'S receipt of the hearing request. Assignment of a Case - Within 30 days of the receipt of the hearing request, the legal technician Step 2. Request for identifies the documentation to determine PRRB'S jurisdiction over the Jurisdiction case. If the documentation is insufficient to make this determination, the Dacuments legal technician requests that the provider submit additional documen- tation within 30 days. - Within 30 days of the receipt of all documentation, the legal technician Step 3. Jurisdictional evaluates the information and determines whether the case meets PRHII’S Determination jurisdictional requirements. When there are complex issues or jurisdic- tion is questionable, the case is reviewed by a paralegal specialist or, if the paralegal specialist cannot determine jurisdiction, the Board. After PRRB accepts jurisdiction, the legal technician requests that within Step 4. Request for 120 days both parties submit statements indicating their joint agreement Joint Agreement on on the issues to be adjudicated. Issues After receipt of the joint agreement statement, the legal technician Step 5. Request for requests that within 60 days both parties submit papers showing their Position Papers positions on the issues to be adjudicated. IJpon receipt of position papers from both parties, a legal technician Step 6. Review of reviews them to determine whether the issues addressed are the same as Position Papers those in the joint agreement statement. If so, the file is forwarded to the hearings and decisions staff for further processing. Page 36 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Appendix I Description of the 17 Major Processing Steps in PRRB’s Appellate Process The hearings and decisions staff review all documentation to familiarize ste@7eReview Of Case themselves withthecase. by Hearings and Decisions Staff If all documentation supporting the case is in order, a paralegal special- Step 8. Scheduling the ist arranges a date for the hearing. Heqring ----- Both parties are notified of the date selected for the hearing. Step 9. Notification of Hearing The paralegal specialist drafts the Chairman’s opening statement and a Step 10. Opening list of all correspondence and documents submitted by both parties prior Statement to the hearing. The hearing includes the board members, the paralegal specialist Step 11. Hearing Is assigned to the ease, and representatives of the provider and the Helid intermediary. The paralegal specialist confirms that each party has received a copy of Step 12. Confirmation thetranscript of Receipt of Transcript The paralegal specialist ensures that both parties have submitted Step 13. Posthearing posthearing briefs. Briefs Submitted Page 37 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Appendix I Description of the 17 Major Processing Steps ln PRRJYs Appellate Process Following the hearing, the Board schedules a conference to discuss the , Step 14. Decision outcome of a case. Conference Scheduled During the conference, the paralegal specialist presents the facts, con- Step 15. Decision tentions, and HCFA rulings pertinent to the case and the Board makes its CoxkferenceHeld decision to either affirm, modify, or reverse the intermediary’s decision. The paralegal specialist drafts the decision. Step 16. Decision Drkfted Step 17. Draft Decision finaldecision Reviewed; Final Decision Issued Page 38 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow Appc#dix II SUpplementalCaseInformation Table 11.1:Average Number of Days Csses’Were in Each Step of the Average no. of Standard Appellate Process (As of Feb. 2, 1989) Step _-.- ---..-__.___ No. of casesa days deviation 1 1,283 278 341 2 370 210 169 3 59 212 116 4 52 37 22 5 414 241 213 6 19 89 61 8 36h 44 81 9 15 64 52 10 . ..-___- 5 83 87 12 12 34 20 13 2 17 4 ------..- 14 9 4 4 15 3 21 22 16 1 29 17 9 46 44 Total 2,289 “Analysis was limited to appeals in the automated data system “In total, there were 37 cases in this step. We excluded one case because the average number of days in step was not known. Table 111.2: Projected Disposition of Cases In PRfkB’s Manual Data System (As of Status No. Feb. 17, 1989) -.__ Active 1,076 -.----- In suspension 16 _--_..-___ Also counted in automated system 32 Inactive ---- 252 Unknown 206 Total 1,582 Table, 11.3:Projected Distribution of “Actltie” Cases From PRRB’s Manual Stepa ----._----- No. ___-. Data System by Step in the Appellate 1 190 Process (AsofFeb.l7,1989) 2 680 5 206 Total 1,078 “All cases in the manual data system were in step 1, 2, or 5. Page 39 GAO/HRD-90.23BR Medicare Part A Appeals Process Slow Appendix III CommentsFrom the Department of Health and Human Services DEPARTMENTOF HEALTH & HUMAN SERVICES Mr. Lawrence H. Thompson Assistant Comptroller General United States General Accounting Office Washington, D.C. 20548 Dear Mr. Thompson: Enclosed are the Department's comments on your draft report, "Medicare Part A Provider Reimbursements: System for Processing Cases Weeds Improvement." The comments represent the tentative position of the Department and are subject to reevaluation when the final version of this report is received. The Department appreciates the opportunity to comment on this draft report before its publication. Richard P. Kusserow Inspector General Enclosure Y Page 40 GAO/HRD-90.23BR Medicare Part A Appeals Process Slow Appendix III Comments From the Department of Health and Human Services - c2oment.sof the Ceoartmentof HealthandHumanServices on the General Accountim office Draft Fkatmrt, Medicare Part AProviderPeimbursemets: System for Processing Oases Needs Improvement" Wehave reviaJedGAo'sdraftreportandareencouragedby GAO's overall conclusiohsthattheHealthCareFimncingAdrninistration (HCFA) andthe Provider ReimbursementReviewBoard(PRRB,Board)arefunctioningina manner consistent with their legislatively prescribed roles. We are also pleased that the report reflects the fact that HOF'Ahas not attempted to interfere with the functioning of the Board by restricting staff allocations. TheOA findingsmadeduringits on-site audit at the PPPSbetween October 1988 and February 1989 appear to be an accura te assessmeht of the PRRBduringthatperiod. However, chahges inplwBprccess, implemented in May1989, andtherestructuring oftheJurisdictionandCaseManag~t Staff have forthemstpart renderedthese findingsmoot. In early 1987, the prior Chainmn of the Board determined that a reorganization of the support staff was necessary to facilitate the processing of an increased workload (1,864 requests for hearing were received in FY 1986) and to address the new problems presented by the implementation of the hospital prospective payment system (PPS). The reorganization plan divided the E?oardsupport staff into two divisions. Itaddedsupervisors amlsubjectmtterexperts andrestructured staff duties with the intent of enabliq the Ekxmdto continue to met its respmsibilities with lower graded employees. For example, in addition to having advisors at lower grade levels (a classification audit proposed a reduction in the journeyman advisor position from a OS-14 to a GS-13), the Board planned to train a part of the clerical staff to handle legal techniciantypeduties in the jurisdictionandcasemanagemntprocess, relieving the Board advisors of this responsibility. At the time this reorganization was planned, the on-board strength was 26 full time equivalents (FTEs), and the board estimated that 29 FTEs were needed to effectuate the reorganization. This reorganization was implemented in March 1988. The additional !?IEs, hmever, were not forthcoming, and, in fact, the staff allocation of the Boardwas reducedalohgwith theallocations ofotherHOFAcmponents. At the sametimethen~ofappealstotheBoard,wfiichhaddropped in Fy 1987 to 855 frcnn an all-time high of 1,864 the previous year, began to increase onrx more and rose to 1,519 in FY 1988 and to 2,241 in FY 1989. WhenGAOinitiated its study in October 1988, the Board had just completed a year of low productivity. Factors that ccmbined to severely impact the productivity of the Board in FY 1988 were: (1) the inpact of the reorganization - new duties were added to sme positions and there were changes in supervision: (2) staff losses in critical areas - Board advisors and legal technicians left for retirement or new jobs: (3) the implementation of an automated proces sing and managementinformation system which necessitated diverting the efforts of mny of the staff to Page 41 GAO/HRD90-23BR Medicare Part A Appeals Process Slow Appendix III Comments From the Department of Health and Human Services Page 2 reviewing and sortingcases, determining statusofcases, etc., for con-ectenteringofthereguisitecasedata; (4) agrowingworkload;and, (5) the relative inexperience of staff that were assigned new duties in the juriedictionandcasemanagemshtarea -the jurisdictional questions thatarosewiththe inflwrofnewcaseswereofunprecedentedcamplexity becauseofPFS. At the sametime that GAOwas beginning its study, the E@ardleack-shipwasevaluatingtheEkoaxd's IT1988 performance. Despite the unique, nonrepetitive nature of the elements affecting the low 1988 output, the Chainmn and the Executive Director decided that the Hoard's operating process should and could be further inproved to more effectively processtheincomingcasesandmaximizethentrmberofBoardhearings. GAO's study and probing guestions reinforced this idea. In May 1989, the Board issued instructions to intermediaries and provider representatives that drastically &anged the way the Eoard managedand processed appeals. More responsibility has been given to the intermediaries andthe providers inpreparingappeals forhearing. Under the newprccedure, once the F!oarddetemines thatatimely appeal has been filed, the parties are responsible for meeting to agree on the issues in question, andthe intenri&iaryis askedtoadvisethe Ekmdofany impediments thatexistto Doard jurisdiction. Ifthereareno jurisdictional impediments, and a jointagreemm t on the issues statement has been submitted, thecaseis assignedamnth forhearing. No further action is required of the parties until position papers are due 2 months beforethe first day of themonthofhearing. (No action is required at the Soar-d during this time period either.) Questions or problems that arise during this process are handled by Hoard analysts with legal backgrounds. Thesetiificationstotheprocesshavechanged the job skills neededby thepxsonnelof theJurisdictionandC!aseManagemehtStaff. Legal technicians are no longer required since the routine decision making is hahdledbytheparties inthe case. The non-routine problems or questions reguiremrehighlytrainfxlandskilledemployeesnecessitatingthe recruitmntoflawyers orlegallytrainedanalysts. The Boarclworkedwith HCFAin establishirq new legal analyst positions to replace the legal technicians. This has resulted in an overall increase in job proficiency inthecritical jurisdictionandcase~g~tarea. A contractor was hired to input data into the Board's automated system. Ihis contractor entered all backlogged appeals and related information into the system. Itn~entersnewappealsanddocketsallcorrespondence upon receipt. Cases in the systemarebeing autmatically screened, and status requests, in the form of letters generated by the autmatic screeningproces s, are being sent to the providers where no current action has taken place. Cases are being closed where appropriate. Old cases that are stillactivearebeingconsolidated intothenewprocess inan orderly fashion. Conseguently, the replies to status reguests and the Y Page 42 GAO/HRD-90.23BR Medicare Part A Appeals Process Slow Appendix III Comments From the Department of Health and Human Services Page 3 consolidation of old, active cases intothenewprocess have enabled the EUardtogetamreaccurate asxsmeht of its workload. In addition, the modifications to the proms shaveeliminatedprocessingste~ 2 and3, whichwere specificallymentioned intheGAOreport, andthetime frames forthosepartsofthecasemnagemntprocessthatremainhavebeen changed. In m, theGA0 studypointedup scmeproblernareas inthe Board'spIofx?ss whichhavebeehmitigatedby subseguentprocedural changes. More importantly, the Board was able to mke significant gains inthenuzbersofhearingsandconferences held at-d decisions issued in FY 1989. In that year, the first full year under the reorganization and under the direction of the new Chairman, overall productivity increased significantly over the previous year, i.e., 75 decisions were issued, an increase of 87 percent; 76 hearings were held, an increase of 41 percent: and, 132 conferences were held, an increase of 21 percent. These significant gains, in areas that the Board considers itsmost important endeavor, were not directly reflected in the segments of the operation thatwere reviewedbyGA0. While it is certainly important for the Board tohavea reliablemethod for controllingitsbacklogand tomaintain realistic time frames for its processing steps, one can't lose sight of the Board's ultimate purpose which is to give those providers that want a timelyhearingtheopportunitytohaveone. TheBoardhasdeteminedthatas currently configured, it can hear a maximumof 123 cases (live or on the record) during a year, based on the number of available days and the average length of the hearings and conferenc3es. In FY 1989, 85 live hearings were scheduled and 29 record hearings held. Thus, 114 hearingswerescheduledoutofamaximmof123 whichwouldbepossibleduringayear. Hmever, 38 live hearings (45 percent) were canceled after the schedulehadbeen set because the parties settled the issue(s). The majority of these settlements occurred virtually on theeve ofthescheduledhearihg. l'heselasttiute drop-outshavea significantimpactonthenmberof cases that the Board can hear and are the one factor over all others that ultimately affects thenmberofhearings andconseguentlythenmberofdecisions that the Ekxxdcahissue. These last minute resolutions occur because providers and intenxdiaries rarely seriously attempt to settle a case until after it has been scheduled by the Board. Thepartiesmayhavewhatthey consider legitimate reasons for this approach (workload problems, etc.), but this phenatmon virtually destroys the Board's ability to maximize its scheduling potential. ThenewBoafdprocessisanatte@toestablishan environment where the parties will met and seriously attempt to resolve their dispute before position papers are developed and hearings scheduled. If the E!oar.dis successful in this endeavor, it will be able to provide timelyhearingstothosepravidersthattrulywantandneedtheircaseto beheardtiwillalsobe able to reducethependingcaseload. Response fromtheintenxdiazyandprovider connnunitieshasbeen exkemely positive. Hmever, the Board will not be able to assess the effectiveness of its plan until it has operated under this process for a period of time. Page 43 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow -... .-c _--- .___.-_.- A p p e n d i x III C o m m e n t s F r o m the Department of Health a n d H u m a n Services P a g e4 Finally, withmspecttothegrclwing inventory o f FIXFIB-, webelieve th a tth e r e a r e s te p .5 th a tco r tgressmighttalceto incrase th e B o a r d 's p r o d u c tivity a n d e fficiency. CmgressaxldaddasixthBoardmmker whichwculdallowtheE&mItoholdcc n c u r r e n th e a r i n g s w i t h 2 p a n e l s o f 3 m e m b e r s e a ~ ,th e r e b y d c x l b l i n g t h e B o a r d ~ s ~ ~ tp o te n tial. C o n c u r r e n ttle a r ~ s a r e n a tworkablewiththeBoard'spresent c o n fig u r a tio n b e c a u s eo f a x r e n t r e q u i r e m e n tsfo r decisions. W e i n t e n d to e x p l o r e this s q g e s tio n fu r th e r i n t h e n e a r fu tu r e . Page 44 G A O /HRD-90.23BR M e d i c a r e Part A A p p e a l s P r o c e s s S l o w ~Md,jorContributors to This Reprt Susan D. Kladiva, Assistant Director Human Resources W. Stuart Fleishman, Assignment Manager Division, Sherri K. Doughty, Evaluator-in-Charge Washington, D.C. Veronica Scott, Evaluator William A. Eckert, Social Science Analyst Virginia T. Douglas, Reports Analyst Jonathan A. Barker, Senior Attorney Offike of General Counsel Y (IIH2*5H) Page 45 GAO/HRD-90-23BR Medicare Part A Appeals Process Slow
Medicare Part A Reimbursements: Processing of Appeals Is Slow
Published by the Government Accountability Office on 1990-02-09.
Below is a raw (and likely hideous) rendition of the original report. (PDF)