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Latest Updates to the OCPM

The Office of Medicare Hearings and Appeals (“OMHA”) has been updating the OMHA Case Processing Manual (“OCPM”) since the Medicare appeals final rule became effective on March 20, 2017. As an effort to regulate and codify procedures for adjudicative functions through statutes, regulations, and OMHA directives, the OCPM is regularly revised to stay up-to-date with the Medicare appeals process.

The first major recent revision to the OCPM was eliminating the four divisions: Part A/B Claim Determinations, Part C Organization Determinations, Part D Organization Determinations, and SSA Determinations. The revised OCPM is no longer divided and consists of twenty consecutive chapters. In May 2018, the OCPM added new chapters 1 and 20, and revised chapter 19. In July 2018, the OCPM revised chapters 5, 6, and 7.  Most recently, on November 30, 2018, OMHA published new chapters 17 and 18.

Chapter 17 is entitled “Dismissals.” It addresses reasons why an ALJ or attorney adjudicator may dismiss requests for hearings or a review of reconsideration dismissal. For example, the reasons an ALJ may dismiss a case include, without limitation, an untimely filing, failure to cure a defect in the request for hearing, or failure to appeal.  On the other hand, an attorney adjudicator may dismiss a request for hearing only when the appellant withdraws the request for hearing.  The chapter also outlines the information that must be contained within a dismissal order, the impact of a dismissal on a case, and the circumstances in which an adjudicator may vacate his or her dismissal. Lastly, the chapter addresses the right to appeal an ALJ’s or attorney adjudicator’s dismissal order.

Chapter 18 is entitled “Requests for Information and Remands.” The chapter authorizes OMHA adjudicators to use requests for information and remands to obtain information that is missing from an appeal. OMHA adjudicators may also request that a prior adjudicating entity take an action or issue a new appeal determination. In addition, parties to an appeal (e.g. an appellant and a CMS contractor) may jointly request that a case be remanded to the prior adjudicator. They must give reasons why the appeal should be remanded, and indicate whether a remand will likely resolve the matter in dispute. Within 30 days of receiving a notice of remand, either party may request that the Chief Administrative Law Judge or a designee review the remand and, if it was not authorized by regulation, vacate the remand order.

The Department of Health and Human Services posts quarterly notices to the Federal Register regarding the most recent changes to the OCPM. The latest notice contained changes made from July to September 2018. The notices provide a summary of the changes that have been made. Appellants should review these notices to remain up to date on the Medicare appeals process.

Wachler & Associates will stay up to date with changes to the OCPM and other current healthcare topics.  We have the expertise and the dedication to aid you or your healthcare provider in appealing a Medicare claim audit. Furthermore, if you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at (248) 544-0888, or via email at wapc@wachler.com. You may also subscribe to our health law blog by adding your email at the top right of this page.