>> no. it is an option for them. >> will okay. all right. i yield back. i thank the patience of the chair. >> thank you. we're going to take a recess. vote have been called, and so we're headed that direction, and we will recess until the conclusion of the votes. the votes, i would estimate, are going to take somewhere around 30 minutes, maybe a little bit longer. then we'll go through, and we will reconvene at that time. >> great. [inaudible conversations] >> apologize for the delay there with the votes. we do not expect votes to

interrupt us. since we're voting about 9:00 is our next vote series, if we're still meeting in our hearing at that time, this will be not a good sign. [laughter] so we don't anticipate that as well, but i do apologize. the 30-minute delay ended up being about an hour and 20 before it was all said and dope. we will go back and forth here to be able to process through questions. i'm okay if we just start opening up questions. ms. duck worth, is that all right with you? so we'll kind of turn clocks off. i have no particular order on that, that way if you want to be able to interrupt during the question time, you're able to get a follow-up question to anything made. that changes our format some, it won't change yours. we typically do a very structured five minute time during our first round, our second round is a more open process where any member can ask a question at any time. just so if you make a statement, the member that asked you the question is not limit today the one that does the follow up, is that fair enough?

so we'll just open it up to a more conversational style. >> i'm here to answer questions. >> great. it doesn't change what's happening on your side of the dais, just our process. i do have a question on the numbers that you submitted to us on the recovery audit appeals work, percent increase in non, in the nonrecovery, i should say. i want to be able to go through a couple of these with you. you list out on the disposition outcome rates fully favorable, partially favorable, up favorable, remanded, dismissed and other. can you give us a quick definition on what that mean toss the provider for each of those and the process that happens. fully favorable, obviously, they've overturned the previous two, it comes back. partially favorable, there's a little bit of a change. i'd like some definition there. unfavorable, they lost entirely. they're going to appeal to the fourth level at that point. give us partially favorable, what that means, remanded, dismissed and other. >> partially favorable. our appeals consist generally of

a number of claims that will be submitted with each appeal, and so a partially favorable decision would say that some of these claims are pay and some of these claims are not payable. so that would be what that is. >> so fully favorable if a provider comes in and they've got ten different cases in front of you, they won all ten of those, it may be that's another provider that brings in ten cases, they won seven or two of them, whatever may be, so we don't know whether they won one or ten in that case, correct? >> exactly. >> unfavorable, they lost all of them. >> right. >> okay. tell us about remanded and dismissed. >> remanded, we do have some authority to send cases back to the lower level or to the quick if there is information that we need from them and that information's only available to, you know, from cms and its contractors. and so we can do some limited remands. >> okay. it was part a that seems to be the percentage that's actually being remanded and coming back. do we know what happens then once they go back down to the

second level, what occurs? >> well, actually, with most of these they have come back to us, and this large number was related to the part a/b policy issue which was resolved by cms through rulemaking, and so those are coming back to us. .. you're talking about it's coming back to us and then it went to fourth level; it came back to you? >> yes. >> what does that mean? talk us through how that happens. because this is a very high number here. as many are remanded as are found favorable, partially favorable and unfavorable combined. >> yes. and in these cases many of the judges decided to remand them. you know, they're basically questions about whether or not claims would be paid as inpatient claims you should part a or whether they would be paid as outpatient claims under part

b. that was the basic issue. and so in order to get many of the judges felt they needed additional information in order to make that decision, and they sent these claims back to the lower level to get that information. what has happened as a result of cms' rulemaking -- and these cases are actually going to be coming back to us, and i think they have come back to us. >> okay. so they're remanded. you got the additional detail, it's now coming back to you. how did that come up here on our statistics? what we're trying to evaluate is what's really happening in these cases. it's hard to be able to tell what's really going on. >> well, and we don't double t portanem, i think th >> and we don't double count them. i think that's the important thing.t do they don't recount into our receipt levels when they do come back to us. because they're not fully disposed of. the cases are still needing an

adjudication at our level. so when they come back to us we adjudicate them within the process and then we would send them on. they either get paid or, you know, if they don't debate and many of them will get appealed. >> so i'm still trying to track this. they have gone through the first two levels at cms. they come to you. there's not the information you need, you're renaming it back to cms. they're getting additional information and then comes back to you again? >> yes. >> there are five levels so far. escaping, five different events within the first three levels -- >> five handoffs. >> they're coming back to you again and then i should look at this remand it is sit back, it would be basically the same percentage between fully favorable, partially favorable and unfavorable friend? using it is not double counted. >> no, it's not a double count.

>> but when it comes back to you again i should expect it to be something similar to this percentage that is coming back? what happens when it is remanded? are they more likely to be favorable or unfavorable when he comes back after being remanded? >> the remand doesn't predispose it to any sort of disposition when it comes back. when it comes back to us we adjudicated as -- as all of the claims. we will have a hearing on it and make a decision. >> so this is somewhere around 60%, part a around 60% been found fully favorable when they are coming to you. i expect it is about the same percentage coming back again? once they are remand and it gets to that, so basically if they are very, very persistent in part a at least, pretty good chance they will be found fully favorable? >> i think the percentages hold true then you can use those percentages to say what will happen with the remand when they come back. >> that's approximately how

long? getting to the first time, they have consumed three years and the process. then it gets remanded. it goes back to cms. handle it in three months, whatever it maybe and then they are waiting back in line again and that may be another three or four years to get to you? a remand is an incredible amount of time. >> it's my understanding that these cases are really already back with us, that they were sent back in bulk and so these are already back in cuba. -- in thank you. but as far as how long that is, that's a number of up to get back with you on. >> that's what we're trying to figure. a remand is the new number were trying to track based on what we got last night on the. i'm trying to get if it is three years to get a decision to get remand, goes back and back in the queue again so now we are up to six years minimum to get fully through all five of those

steps. >> i believe, i will check on this for you and clarify it but i believe that they retain their spot in the queue windier remanded. >> so once cms makes a decision they're right back to you again quickly. >> and right back into the key e where they were when you left us. because we haven't given up jurisdiction of the claim. we send it back for more information, but it's still with us or to generally it would come back to the same judge who had it when it was sent, when it was remanded. this year was an aberration. you know, it was a very, very high number. we are not seeing that in subsequent years, and we didn't see in previous years. >> okay. you feel that's because the whole issue of inpatient, what is outpatient, is that what is unique? >> correct. >> is this do with the two midnight rule and all that's

because yes. >> what a fun rule. that is going really, really well. the hospitals love it. >> we're waiting to see what impact it will have at our level. we have not seen the impact of that rule at our level yet. >> i have yet to find a fan of the rule anywhere. that's one of the issues that doctors and hospitals raised in sicily sank this the facts our decision-making. it wasn't your decision, i'm not blaming you but i would expect would be quite a lot coming at you because there's a tremendous amount of frustration around that particular rule. >> and i think this is something we're watching in need to watch. we need to continue to see what the appeal rates are in part a and part b, inpatient outpatie outpatient. >> two more quick questions and want to go for sure this time as well. that dismissed and other. >> yeah, the dismissals are cases where for one reason or another usually it's because the appellant has improperly filed their request for hearing or

perhaps they have abandoned their request for hearing in the process by not showing up for hearing and that sort of thing. and so the cases are dismissed at our level. that is a final disposition of those of us vague appeal the dismissal to the medicare appeals council. >> so that is an unfavorable raised on either didn't show, didn't i'll, didn't complete the process. they started but didn't complete it? >> correct. >> by the previous decision would stand which was unfavorable? >> which becomes the final decision. >> what is and other? >> the other i will actually -- escalations, it would include escalations to the institute, the medicare appeals council we have about 152 of those. occasionally we have an expedited access to judicial review but those are very, very rare. >> okay, thank you. >> thank you.

i'm still a little flummoxed by this remanded number. i just added up the fully favorable, partially favorable and the unfavorable and came up with the number 21,846, which is nine from the 21,855. so this remanded number that you say gets back in the queue, are they getting back in fy '13 or a be getting back in the queue in fy '14? >> day, i believe that they came back in fy '13 or early fiscal year '14, right about the time that cms administrators have and are -- cms administrator tavenner released a ruling on this. >> but this number is so close and maybe that's just part of the aberration. that would mean that virtually every one of these cases was remanded because there was

inadequate information. >> no, these are not -- it's not a cumulative number. i understand that they're close to the same amount but the remand's are exclusive of this fully favorable, partially favorable and unfavorable. it's a separate category. >> so it's a separate category which would mean that we are not talking -- we're talking about close to 50,000 just in part a if you take all these numbers and add them together, give or take. >> yes. >> okay. all right, let's, let me ask you this. aljs don't have medical training, correct? >> no. as a general rule they don't. i don't know whether there are any who actually have dual certification, medical and legal but they are attorneys who have been selected off the register. >> because they don't have medical training, they are somehow trying to determine whether or not a procedure was

appropriate or not appropriate, correct? >> reasonably medically reasonable and necessary, yes. >> is that system flawed just at the outset? >> well, we had some extensive training for them that is conducted. when they come on board we do a training session for them that goes over very much of this, but lawyers are involved in medical-legal issues in many, many areas. >> they are abdicating typically for one side or another and not judging whether something is appropriate medical procedure or not, whether someone really needed this -- it's more of a philosophical question. obviously we've engaged in this for a long period of time. i just find it somewhat odd that in the end there are attorneys like you and me who have been trained a certain way that don't know whether this was an

appropriate procedure or not. >> well, but in essence what they are doing is making a judicial decision that is based on the evidence that is going to pursue them. in our setting that includes the written record, the documentary evidence, and generally during the course of hearing also some explanation of medical necessity from either a provider or supplier of the services. and so that is, you, that's kind of the way the system is set up for us to be able to rely on these opinions. [inaudible] >> essentially it's the same thing. we look at the record to determine whether they have been met. >> i think we're all troubled by the fact that 54%, least that's

the record we have heard, of the appeals in part a are sustained. now, you said earlier that the figure for the first part of this year is less than half that, that were fully favorable to fully and partially to me need to be locke loved together. what is the figure for 2014 for fully and partially favorable? >> i don't have a percentage for that. >> could you get that force the? >> i certainly can. >> here's the dilemma i see. 54% of appeals are sustained. so in the medical profession if you've got a better than 50/50 chance of being sustained, you're going to appeal. so your volume is going to continue to increase as more and more providers recognize a, this is a pretty good, your odds are pretty good here. when you have an alj was looking

at a set of circumstances, if not a physician but is trained, and is looking, well, from my perspective as someone who is not in the profession, it could be a close call if the procedure has been performed. it's not like there hasn't been a service that hasn't been provided in most of these circumstances. so you're going to air in favor of sayin think of it, we will sn this appeal. so at some point i wonder whether we have diminishing returns here. that's more of a provocative question, rhetorical question at this point. but i do think that the construct probably should urge us to think about whether it's the way we should be doing these appeals. >> i would like to clarify one

thing, which is the percentage is you're looking at are on the recovery audit appeals. and the reversal rates on those appeals have been higher than the general reversal rate for the agency, which is it includes all the appeals. so for 2014, and again the numbers i have are fully favorable decisions, that i he s just 19.3%. the numbers have been -- i'm sorry, that was three favorables. i keep going to the number. i will get you a number on the reversals. >> the other thing i've been told is that when cms actually is present at these hearings that the decisions are not sustained. but that cms representative is oftentimes not present. so that suggests to me again that we have a system that isn't

operating properly because we want fairness across the entire spectrum. so one provider shows up, has their appeal and the cms person shows up, and it's not sustained. but another provider shows up, same circumstance but the cms person is not there and it is sustained. we are not providing equal protection under the law. >> let me -- the cms -- but we have found, and there's very limited data on this and it does come from cms, but when it is cms participation in these hearings, the reversal rate does go down. and -- >> by how much, doing of? >> i think about 6% of the remember correctly. it was from about 46%, only over a few months of data that we have, i'll get you the exact numbers. but from about 46% down to 40% is -- yeah, 40%.

>> and as far as the reversal rates go, i've got that number now, which is on the disposition. the overall, the overall favorable rate in 14 is 35.2%. we have been doing a number of things which have been designed, to bring our policy interpretation in light across all levels, to develop consistency in education. part of that is training, and we've had approximately 20 training sessions have been delivered by cms, their doctors, and their policy experts to the administrative law judges since 2010. and so what you will see if you look at the historical david is that the reversal rates have actually been going down.

they were at a high in 2010, 55.5% fully favorable, and that is now down to 35.2%. >> i think the training efforts have a lot to do with that. >> i think you would have a better quality of decision because you have to do with every case if it has to make a decision. so the question is, they case is coming to you, but you do make better decisions at a lower level or at their something that's happened at the alj level with the better trained that you are making their decisions and the decisions earlier, you were finding people fully favorable more often that will would be consistent with policy. >> or the joint training leads to better consistency among adjudication level. >> i was still me as somewhat you've got people making fully favorable decisions that should've been made partially or unfavorable if you're saying better training a six that that would say there was an issue at some point that we were doing too many fully favorable and partially favorable. >> i don't think i would go so

far to say it fixed it, but i would say that it has improved it. i do think the goal is, you know, as congresswoman speier point out, the goal is to have the case paid if it is a proudly -- paid a early in this process as possible and keep them from reaching the alj level. >> mr. chairman, may i add a little? >> sure you can. >> i want to touch on this. is their training coming from you to alj down, back down to cms back to cms? is cms accepting that direct audit? i'm going to use an example that's happening in the orthotics and prosthetics industry where after an artificial limb is made and delivered to the patient, the claim is being denied iraq audits because the actual word patient is -- of a amputee does not appear in the physician's note. but the workstation guard artificial limb or prosthesis up

your and the medicare history includes payment for the search and to conduct a limb amputation. and so many of these denials could be eliminated if when they get to -- these are getting reversed at alj. is their feedback going back down to the same as saying, look, just because the exact word does not appear in the surgeons note that the patient is an amputee doesn't mean that you deny these, because if you book it says that the physician is saying they need a prosthetic and we pay them to indicate a limb. and so are you and cms and rac audits looking at different records? are you -- because, you know, -- >> no. i mean, as a general rule we review the same record. now, there are some exceptions to that. there's a good cause exception which allows additional evidence to be presented at the alj level

that we are supposed to be decided based on the same record. what does changed immediately is the fact we do have a hearing, and so at our level we are able to question the providers, suppliers, receive some explanation and then make a decision that becomes part of the evidence that's in front of us. >> my understanding is the auditors are not allowed to consider the omb professionals note, but those notes are considered part of the physician's record and they showed on the physician's record. so the person who makes the artificial leg, his notes, rac auditors are not allowed to look at his notes. daily look at physicians does. when you look at the physician's note you look at in tidy which includes the person, the notes. is the feedback coming from you to cms to allow rac auditors and the lower level to say, you need to look at the prosthetics notes

because your pushing people in the system and it's ridiculous when someone is being, you know, something as simple as patient isn't npt, is missing from a record from a guy we paid already to have his leg amputated. >> and we do have regular meetings with cms and with their appeals, their appeals group within cms. i think those happened on a weekly basis? weekly basis. when we identify a trend, we would bring that up at those meetings, or that was significant trends i would bring it up with marilyn tavenner. i'm not, i'm not aware of the specific instance that you are describing. >> all, it's more than one. we have 100 orthotics and prosthetics in this country gone out of business waiting to be reimbursed. and have gone out of business. and there's more than one. i am sure that we can get you a lot of those examples. >> if we become aware of them i think that's part of, you know,

part of the issue. our judges are individually adjudicators. and so we have to become aware that there is a trend and when we do, we have those feedback loops in place, and we are able to do that. >> how do you spot a trend? you have a system in place to figure out to find those transcripts. >> i just want to reiterate what the gentleman from illinois was talking the. she is exactly right. this is not just unique to a particular group that has told. i me, we've got physicians who literally go through step one in step two that have complete records and it has to go to you before you look inside josh, it's a complete record, and they waited -- oh, gosh, it's a complete record. and it's crazy stuff, ms.

griswold. she's given that. i've got examples. after this last hearing we started hearing from all over the country from claims that were denied because the date instead of being at the top was at the bottom. or the physician, you know, has signed his name in this spot and they weren't taking -- i know we can't fix stupid but it seems like that's what we've got to do here because it's just, i mean, a reasonable person would do this, and you talk about trends. i don't know how you define trends because you've got adjudicators who are adjudicating across the omha system. so one adjudicator seeing is a trend in his or her jurisdiction, it doesn't work. and so i just, i appreciate the gentlewoman yielding and i yield back. >> i just have one final thing,

and that is as you go to meet with the newly confirmed secretary bauer well, i was hoping that you would consider having a conversation with her about granting the same kind of relief from rac audits that were being granted hospitals under part a through the two midnight rule to part d providers like those in orthotics and prosthetics. ever going to credit to the hospitals under part a, i think that we need to consider granting it under part b, especially since there's a halt to the hearing at this point. thank you, mr. chairman. >> ms. griswold, did you want to jump in? go ahead. >> thank you, mr. chairman. at the risk of quite frankly highly gone now in the last couple of comments and statements, i have the same concern. i applaud that you've introduced new initiatives so that your productivity is better but now i'm minimizing my information

says that the average hearing is now two hours, and given the complexities although we haven't talked about the complexities, we talk about the easy stuff. i'm not sure it gets address. while i know that given that we now have an incredible backlog and we are struggling with this, it's time to do more than just sort of figure out the steps, we're touching these cases, how we are cross communicating. .. is nobody on this committee, and i daresay no one in congress, is willing to tolerate waste, fraud, and abuse. we want you, everyone in the system to do everything you can, not just to minimize it, eradicate it. these are clearly administrative issues. while i do, i expect providers to be as administratively competent as they can, i can't with consistency, and i'm a lawyer, even read a medicare

dob. given that, the likelihood that you make mistakes, simple, the form says that the date at the bottom of that form is updated issue. i've got 200,000 foreigners from last year and instead of throwing those away, no one pays attention to that. the fact you are viewing the sunroof of fraud and abuse contacts in a thing that is important, but we are closing these businesses who are going to be paid and there's a lot of small providers. again, i know you've heard all this and we appreciate and i occurs my colleagues. i thought airiness. because you're a big provider, i don't think a big hospital should have to wait and be penalized in this fashion. otitis credit goal in a frontier state like mine and new mexico, an entire community in a place like gallup or in my district in torrance county, there aren't

any providers. there aren't any durable medical equipment providers, there aren't any oncology providers. none. zero access. we don't have three tools or strategies to re-create these. so i'm really interested as a result of of understanding of the situation between how they are adjudicated, but your initiatives are, how you try to manage these cases. i appreciate the weekly meeting, but i would encourage you to go back to the secretary and be really clear and i think it seems like we are all in the subcommittee and we've got a problem on the front end. so we do one updates. i do. we want information about what you are doing on the backend and i want people to feel like because it is cumbersome that they can win on an appeal, even when there might be a material problem.

but i think the bulk of these updates in the reason you now have half a million cases coming to you on appeal is because they are administrative issues that don't come anywhere close to fraud waste and abuse. we need to deal with that issue sooner than later. i know that there is a comment to make back except the expectation is your take the urgency back because with all the work we've done to maximize access, this effort is minimizing it to the highest degree and a has a chilling effect on our patient population. >> i would certainly take that back. if there is a positive coming out of the situation, i think it is the department is doing the workload or holistic way. although there are three separate agencies, feedback, omha that work with these

workloads, the department is taking an active role in trying to resolve things. so i will take your concerns back. i certainly share them. i would also say i was very pleased when i came here to omha to be part of an agency that had for the most part that its 90 day time frame. as an administrator myself, i find the delays very troubling and unacceptable. you basically have here a workload capacity problem. >> and they get to that for a moment? reconfigure and complain for hours and nothing is going to change because the addition of 17 new alj is, talk about the simple math that make good friend, mr. meadows, had referenced.

there's 500,000 appeals that will be backlogged by the end of this year. divide that by 1220 and you're working at optimal levels and i don't know that you could do any more than that. frankly i don't know that we would want you to do more than that because less than two hours and every cases less than unfair. that would suggest we would need 410 new aljs if we wanted to get rid of the backlog in a year. 410. you have asked for 17 -- or you have been given 17. so they're basically saying to the providers out there, suck it out. excuse my language, but that is what we are saying. we are not willing to deal with this backlog. we're putting blinders on. we will add a few more and crossed her fingers and hope

that with a few new reforms, but it's not going to reduce it to the extent we will not be back here next year for the same discussion. so how would you comment to that quiet speed not well, there are several names. >> i'm sorry to interrupt. but you put your microphone and little closer to you? >> sherwood. they're several funding issues here. in my mind, one of the primary ones that have students recovery audit program and the recovery audit legislation. when congress passed legislation for the program, he was in vision the program would be self funding out of recovery. the legislation provides that the administrative cost of cms will be countered. that does not include the administrative cost of omaha or the administrative cost of the

departmental appeals board. so what we have basically had in that regard is a workload that came in there was basically unfounded. so i think that's part of the problem and it's a part of the problem that i think does have a solution. so if i were queen for a day, that would be one of the simple fix is that i think would be possible. >> many black? >> to in some way properly found and i will put in a plug for my sister agency, the departmental appeals board said a recovery audit appeals to come to the last two levels and our fun night out of the program as they are in the lower two levels. >> so is there enough money that

is recovered to pay for all of the levels of appeals? >> yes, i think that there is. you know, this is based on cms's reports on the recovery is coming from that program. so that is one part is one part a think of the solution. we are doing these two pilots. one about the adjudication model and facilitation. i think we need to look at something like that as well. >> is that being piloted in a geographic location. conference.

cms -- >> give us an example of what that means. real-life terms. >> real-life terms, and it was put on our website on june 30 so it's a very new program and we are waiting to see a balanced response to it. but the theory is that an appellate will be able to come in and ask for a settlement conference with an attorney who is at omha. cms would provide someone better with settlement authority who would be able to discuss merits of the claim and possibly resolve them to ensur ensure thy in the queue encoding. that is the theory. while that is going on they do not lose their place in the hearing to. so they were still remained said they would still remain mayor. but we are hopeful that this will allow us to resolve some of the pending claims. you know, this is a two-part problem.

there is a pending claims we have. there are also to receive coming in. this piece of the solution is designed to deal with the pending cases that are arty witness. >> is that your assumption that the slamdunk cases lacombe back to mr. meadows statement about the signature in the wrong spot and walk in faith not the topic comments at the bottom. is there that kind of stuff coming back at you with the settlements another settlement they left the room out then fully paid or is it fully paid so they are at a faster process to fall pavement? >> you know, i think it depends. like most settlement conferences, it is going to be probably a little bit of give-and-take. that give-and-take. that'll. that will be my anticipation. if it is something in the course of what is the prehearing conference was an attorney point out a simple technical error or something like that in these

claims, it is potential. it is possible they would be fully paid. we have to wait and see how that would work. >> the alternative dispute would be valuable to providers in particular if it was a decision that is going to be made. so that becomes the appeal. >> we are trying to find ways of resolving claims within our pending workload more quickly than we can get them to an alj. we are trying to do that given our current authority. right now, the latest statutory scheme is structured, and appeal cannot get out of step three. they cannot leave without finding an alj. so what this would do, there would be this agreed-upon settlement. both parties with side and the judge would then dismiss the appeal.

said the agreement becomes the claim. >> so the chart that you gave us is a dismissal? long-term? is a fully favorable? >> it would probably be a dismissal, but right now we are tracking them separately as a settlement resolution. >> okay. >> how about the other alternative is that global settlement discussion contact, but claimants that have similar kinds of cases that would all be invited to come and and participate in a global settlement that they could choose not to wake out there. is that correct? >> this is an initiative that is one of cms's initiative and i have to admit that by knowledge on this is limited. you know, it is my understanding that it would be a global settlement.

>> said that what happened before it even got you? >> i think it also contemplates they are looking at claims pending on all levels of the process. >> so we haven't really seen an operational yet? >> no, we have not. it is an initiative that is still pending. >> i know you're communicating back and forth, but you have these regular conversations. i'll do a type of pre-settlement with pre-settlement with mortgage and alj is something they would've rather had with cms and to get this done a long time ago to face to face and resolve this or get on the phone and everybody looks at the same tries to resolve this. the simple straightforward cases want this resolved. if they are physical therapies that is trying to take care of the practice as well as the paperwork coming he does not need bummer thing to do to change this step down into the

hearing and hiring outside counsel is well beyond what they want to do. they want resolution. how can the process by what you are working with as cms. we are trying to figure out how to prevent the backlog. >> rate. among cms's initiative, you will see particularly with regard to recovery audit and i think that could be helpful in resolving this claims that the lower level. >> the ad is something are discussing, not something they do currently. >> i really can't speak to that. i don't know to what extent they have a discussion. right now. [inaudible]

>> okay, okay. i am informed it is optional right now in the rate case. >> at the cms level they can do some discussion as well? >> i think so, but i'll have to check on that. i would rather have cms get back to you on that. >> i don't want somebody to answer for them. we are trying to do some fact gathering as well. again, came to the issue of jailed resolution and ones the contractor grabs it, files that cannot live without their come to bailey's contact and now we're fighting with someone else. they can't get to them anymore because it's too late. they made the decision and file date and the auditor is playing the percentages literally that if they grabbed 10 or 15, they'll get three or four of these at least a payday percentage of each of them.

so it is a whole different game for them. but for the provider, our issue all along is that it is fraud, it is friday we had to bust them. if it is a good provider, they should not be harder. these are the folks we need on our team and that the american people need. >> i fully agree and i think that identified not just medicare fraud, but improper payments is an important piece of this puzzle. but what we have done in the zealous efforts to implement congresses intent in that regard, it is gotten out of balance. and what we need to do is restore that balance at this point between the broadcasters and the appeal rights. so i have spoken with his secretary on these issues and i know she is committed to restoring a. >> you know, i had iraq in my district that was creating a great deal of discomfort for one

of the hostile providers in the districts. it was also a hospital that was under a lot of financial pressure to just keep its doors open. in my experience with that particular situation, suggest that more than anything else, the provider wants to know what is going to be approved. now they could have in fact been on a billing services that would allow for more reimbursement. i don't remember the elements of it. sometimes the providers are in a bind and are looking for ways to code or an bundle services. so we need to be smart about this and not appear to be taking one side or another. everyone should be treated the same. it is so important for there to be some certainty and some

finality and found decisions. i keep coming to this backlog. even with all of these new proposals that haven't even been tested really. so i still think that we kind of do, whether we hire temporary aljs for a period of one year and deal with this backlog otherwise we haven't really accomplished much. >> just to address that, there are very, very limited authorities for hiring temporary aljs. this is statutory under the administrative procedures act. really there are two ways. you can try to get a judge on loan from another agency. most agencies have their own backlog. when we went forward requesting judges, we did not gain any.

so the other way is to hire judges who retired and they are called rehired senior aljs. those individuals are also on the list that is made pain by opm. they can be hired a couple of years and then let go. beyond that, and alj appointment is simply a life appointment except for removal for a good cause. after a hearing. >> so how large is this list of retired aljs? >> how many were there? probably around 100. it's not a tremendously long list. you know, we do have that. we requested it in april because we do think that temporary capacity as a part of this solution to deal with the backlog. now when you're talking about

projected receipt levels, i do think we need to be appropriately staffed for what we anticipate to be coming in. so i don't know if that is helpful, but aljs are non-probationary when you higher up under the aca. there is no probationary period. there are no performance reviews. and they can't receive awards. so those are kind of the things that make them different from other government employees. >> at the gentlewoman would heal, i want to follow up because they are hitting on precisely the point on why it is so incredibly important that you are here today, but it is really about what is coming to you and how do we address that. the bigger concern that i have is even if you hired 100 comments to be shy based on a

simple matter what is going to happen because this doesn't stop today. it is growing exponentially every day. i think it is 1500 appeals at least a week. is that correct? >> it has been as high as 16,000 appeals a week. it has been down slightly at the beginning of this year to 11,000. we are trying to figure over the plateau is going to be. >> i was told by jonathan plum before he left it there is a policy change within cms that was initiated and may be numerous policy changes number but there is a policy change between 2011 and 2012 that dealt with the way they start to referred these to you. part of it is rac and he needed a legislative fix. i question to him was that there was a policy change, why do you need a legislative fix? one i am concerned about is what

changed in 2011 or 2012 to make this number grow that you are getting when we are not seen payments, the improper payment actually go down. so we've seen no progress in terms of improper payments in africa at this huge on our hands and we are not saving any money. so what changed in 2011 or 2012 and i would look back the chairman. >> bow, the big thing is the recovery audit of course. we've got about that. those initially a pilot program in 2009-ish. i think it is for states. >> does an act of congress. he indicated as a policy within the regency. -- their agency.

>> it was than it was probably around that time. where there is a focus on identifying improper payments. that is not tracked as part of our -- we track the recovery audit separately. they cms's efforts to identify improper payment of the old program integrity contract than the others really looking at fraud issues. there was also a coat also a codeine image and some other things like bad, that any time there are efforts at cms's level to result in a denial of more claims, then i level there is going to be an increase in fees. >> but that is my point. it didn't change the improper payments. they may have done that payments. they may have done that and may have been well-intentioned, but we are still increased if you look at the numbers and we had a hearing yesterday, so that is fresh in my mind.

i will yield back. i want to thank the rink a number in the chair for their leadership on this integration is missed without me to be included. >> can i go back to one issue that you raised earlier, which i think i have finally grasped what the question may have been tenacity with their appropriation and how that is handled. of course as you pointed out, the medicare modernization act gave include language which would authorize to be appropriated funds that were coming and no, cover an increase in adjudicators. having said that though, that appropriation still has to be approved. it does have to go through our department's appropriation process. i just wanted to point that out. i would also say with regard to our general appropriation that

you know, we do know we've been living in challenging budget times. in the past five years, the presidents budget exactly only been approved for us and one of the five years. so request that we have gone forward with, even though they would be somewhat modest have really only been approved this year. so we appreciate that. we're trying to do what we can with money appropriated to us. >> and i was approved because it is part of the omnibus bill? why was it approved this year? >> i don't know whether it was part of an omnibus bill or what it is part of, but i do know we receive the presidents budget this year. i'm sorry. >> is there any other statutory for du meter could use?

>> resolutions you would propose? >> i think there are a number of things that are going to be coming through the appropriate legislative process that we are looking. the two that i have highlighted from our two will provide us with the greatest ability to handle workloads and to expand the way we adjudicate claims at omaha. -- omha. there's some things we consider through the department ruffolo, through the proper legislative channel. >> when will you evaluate the settlement process clicks you started june the 30th. so when is your target date of the initial valuation? >> we're looking at a six-month evaluation. >> can you put us on a calendar reminder in six months ended to this committee as well as we can get an appeal for that also. >> we are tracking metrics from that will judge the program.

we would be happy you clued you in that. >> okay, please do. this committee is obviously very interested in that. >> mr. chairman, i don't have any further questions. i went to thank ms. griswold for being so attentive to her questions and sitting around for an hour and a half while we went and voted. thank you for your service to our country. >> a thank you for your interest in this issue. it is certainly one near and dear to our hearts as well. the fact it is near and dear to a lot of people in our district that not only what to do with fraud and waste in improper payment, which is important to everyone, but also to providers that absolutely, firmly coming tension only the process. when they go through it and there's a signature in the wrong place or a date in the wrong spot and they want to get it

resolved, it now takes three years to get it resolved. so goes from the frustration of rac to the obvious solution that doesn't help any of us. finding alternative solutions like what you propose on the settlement process that they could go through the process if they don't like it, they still iran accused to resolve. is that correct? >> now, they're absolutely in the? there's nothing mandatory about the settlement process. at any point they can exit the process. >> they just want an answer. >> they are. that is the key thing if you work thing if you work in a processes, thank you. continue to press on ways we can help in the process because that is ms. speier mentioned, bringing on more aljs will not help us. there has to be another solution to determine how did they get answers. part of this we understand well-designed cms.

you should not have remember getting to you that is getting to you. i'm looking at these percentages and i know we've kicked around numbers, but when i look at the percentages, i pull out the remanded because those are coming back is a different number. i pull out dismissed because that's not fair. when i look at the fully favorable and partially favorable for par day, i am aware of the other numbers showing a 65% fully favorable or partially favorable resolution if they get to you. that is telling me the job is not done on the cms site. you should not have that high of a percentage of a return. there's something being missed. part of the issues we've got to present the ms to get these resolved before they ever get to user you don't have a backlog is high. statistically you shouldn't have a 65% return rate to get to you. that is not a new, but publicly

there are issues on the previous two we've got to get resolved in the days ahead. any comments? thank you as lovers spending the day. we apologize for the long delay. with that, we are dismissed. [inaudible conversations]

>> ambassador gml is coming in is coming in outcome here are the organizations. european food safety authority, medical associations. no problem, but gml is. our obvious part of a conspiracy? if that isn't enough for you, there's a whole bunch of other organizations in his or not organizations with some scientific sounding names. these are real medical and protective organizations. in europe, which is very anti-gmos, all over the world, the epa, which we pay attention to when it comes to global warming or something like that. they say would not pose on a reasonable risk to human health and the environment. and i ul