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 reall

they cannot leave omha without action by an alj. so what this would do, they would be this agreed upon settlement, both parties would sign and the judge would then dismiss the appeal. said the agreement becomes the resolution of the claim. >> is that listed in the chart you gave us as a dismissal? long-term or -- >> it would end up being, it would probably be a dismissal but right now we're just tracking them separately as a settlement resolution. >> the other alternative is global settlement discussion concept, which claim it's that have very similar kinds of cases would all be invited to come in and participate in a global settlement but they could just not to i gather, is that correct? >> this is an initiative that is one of cms' initiatives, and i have to admit that my knowledge on this is limited. but it's my understanding that it would be a global settlement. >> so that what happened before it even got to? >> i think it also contemplates, they're also looking at claims pending at all levels of the process. >> we haven't seen i

it cannot leave omaha without an alj. what this would do, there would be this agreed-upon settlement. both parties would sign him to judge with them dismiss the appeals of the agreement becomes the resolution of the claim. >> so that charity davis has a dismissal? or if it's fully favorable? >> it would probably be a dismissal but right now we are just passing them separately as a settlement resolution. >> okay. >> the other alternative is a global settlement discussion concept, which claimants that have very similar kind of cases would all be invited to come in and participate in a global settlement that they could choose not to i gather. is that correct? >> this is an initiative that is one of cms's initiatives and i have to admit that my knowledge on this is limited. it's my understanding that it would be a global settlement. >> that would happen before? >> it also contemplates they are looking in claims pending at all levels of possible. >> we really haven't seen it operational yet. >> no we have not. it's an initiati

and then the alj workload? >> i can get you that number. hold on just one minute. >> i mean, trends really help you out trying to figure out what the problem, you know, being a health care provider, i mean, you always look at trends about what's happening. so that gives you kind of a workload basis which to delegate resources to. >> most of our recovery audit appeals have been part a, and so you can kind of use that as a gauge. in 2014 41.2% -- oh, i'm sorry. i have the wrong number there. 54.2% to date were recovery audit appeals, and those are predominantly those part a appeals. >> part a. so 50 -- according to hhs office of inspector general in 2010, 56% of the appeals were decided as fully favorable to the appellants, a reverse previous lower level decision. what is the current rate? >> and are you asking about the rac decisions, the rac appeals or just overall -- >> just overall. >> -- overall otrs? all right. in 2014 fully favorable otr rate for the fiscal year to date is 193%. >> gotcha. -- 19.3%. >> gotcha. now, has omha conducted a

. >> can you describe the different types of appeals held by the alj? >> yes, we hear both part a and part be appeals under medicare and we also hear the part he appeals as part of our original charge. the prescription drug appeals. we hear appeals on entitlement. we also hear the part b medicare advantage appeals. >> in percentage of those, which you hear most often those appeals for aljs? >> well come in various. in recent years a pretty significant number of appeals in part a, which is the acute care hospital appeals. >> and those that have been -- would you say 30, 40, 50% of the time with the alj workload? >> i can get you that number. hold on just one minute. >> trends help you out, being a health care provider you always look at trends about what is happening. so it gives you a workload basis of which two delegate resources two. >> most of our recovery audit appeals have been part part a and you can kind of use that as a gauge. in 2014, 41.2% -- and sorry. at the wrong number in there. 54.2% to date for recovery audit appeals and those are predom

we saw alj work, 60% of the aljs were overturned and lot was due to different interpretations of the policies, different things they were doing there so our -- >> are there a set of recommendations dealing with the medicare policies. >> yeah. our recommendations, in our recommendations because they're are some, it is, mainly to clarify, select the policies that need to be clarified. clarify those and educate people in the policies to create less overpayments and less appease in the process. for instance in my written testimony i talk about our home health work, we found with the recent face-to-face requirement, if a physician is certifying that you're he will babble for home health they have to have a face-to-face encounter. we found 3 billion improper payments in 11 and 12 and a third of claims didn't meet the requirement. we don't think a third of the claims are fraudulent. they are complex policies. as people get more used to them they will probably go down. to educate people on policies and make them more clear is the key to keeping the appeals backlog lower. >> my time is up for

we have little data on the alj level 3 appeals at this time. the majority of our appeals are turned over in level 1 or level 2. i will just comment that i think the 2010 data is, i think, the rac process, and observation care has evolved enormously in the last four years that i think it's worth looking at a new set of numbers and data. we know that the rac recovery rate for back to the government has increased, we know the number of rac audits has increased that is why there's a hold on further audits and appeals. we know it's a lot due to rac denials. and so i think we really do need to look at a fresh set of numbers before we start thinking about a 7% number. i can speak on behalf of our hospital, we appeal everything and win almost everything. in our last year, we appealed 92% of the audits that the racs made and we were winning 2/3 of them and the rest are in level 1 or level 2 of the appeals. i think there's a lot of hospitals out there that are similar. >> that's good piece of information, thank you so much. others want to weigh in to tha

is just an urgent need for more aljs, more clerks and more up-to-date technology. thank you for considering my remarks. >> thank you, mr. cline. dr. parker. [inaudible] >> thank you, mr. chairman casey, senator isakson and the center harkin for the invitation. of course, i'm here today because of the power of the pen, the power of the pen to shine a light on injustice. and we can all be reminded that the coal mine safety and health act challenges us to the first priority and concern of all in the coal mining industry to be the health and safety of its most precious resource, the miner. as we been hearing, unfortunately black lung disease is not a disease of the past and as a treating physician i've cared for miners who died at home, who died in hospital, who died in intensive care you know, who died in hospice care and took it after lung transplantation has failed. i still grieve with their widows and their family members. i understand the concerns have been advanced about the accuracy of the medical work of physicians in matters of compensation for coal miners. mo

just to have an appeals side to an alj. the current claims backlog at omaha's unacceptable and unsustainable. omha must make significant changes in how it does business. i look forward to hearing from the chief judge about the initiatives omha is doing to alleviate the backlog. i also want to remind my colleagues that the claims backlog is a problem that congress created. congress has required cms appropriately to the is lent in the attack and are reducing the amount of waste fraud and abuse in the $600 billion medicare program that covers 51 million officiates. this emphasis on program integrity is critical to the health of our nation's seniors and the protection of our taxpayer dollars. this increased scrutiny has not been coupled with additional funds to address the influx of claims and appeals that have resulted. with the medicare prescription drug act, congress created the medicare administrator contract or is, in the recovery auditor contractors pilot program. in 2010, the rac programmers made permanent and expanded n

we know it's a high volume business when we train aljs, we mention that to them. we have as in any other organization some who meet that, and some who go above it, and some who don't meet it. it is not a quota. >> thank you for that. it seems, talking to them, that it feels to them, to many of them it feels like a quota. i just hope you will sit down and find a way to open up communications with them. and again, reinforce what you said to this committee right now that it's not a quota, that it's a recommendation and there's no discipline. i think they just need to hear that, as much of those conversations directly with you. let me shift briefly to the labor and management relations. even with the presidential executive order calling for labor management partnerships throughout the federal government, it seems from our reports that it's only gotten worse, to the point some labor organizations tell us it's as bad as it gets in the entire federal government. what explains this? why is this? and can i have a commitment from you to provide my office and this committee

griswold, because i've had some great conversations with really folks within the alj. there seem to be a very -- seems to be a very compassionate desire the fix the problem, so that's what we're looking for here today. my other concern, though, and i think the concern of the american people is this whole process of in terms of when we go after waste, fraud and abuse, if we cast such a wide net, then we're taking the decision making away from doctors, health care providers, hospitals, many people who make their decisions who are trained, who go to years of training to do that. and we're transferring that decision making capability because of reimbursements to, actually, a bureaucrat. for me, i have a lot more trust in the nurse or the doctor that cares for me than i do somebody that works here in washington d.c. i think that polls would show that to be the fact as well. so what i'm looking for specifically, and it will be difficult, i know, because you're all part of an agency, but there's this wall of separation that somehow goes up that the american people don't under

first, we support the alj appeal reforms outlined in the november, 2012 hhs office of the inspector general report. second, we support education to increase support. lastly, we support increased dialogues to improve the direction of the program. we are pleased to be a part of the dialogue today. i appreciate the opportunity to appear before you all today and would be pleased to answer any questions that you may have. >> thank you, dr. siey. >> thank you for the opportunity to testify today on observation status, the to midnight rule and related issues. i'm a physician in madison, wisconsin. i'm a hospitalist, which is a physician who cares for patients primarily in the acute care setting. i'm also a member of the association that represents the nation's more than 44,000 hospitalists. to a physician and a patient, the care provided is indistinguishable, but is considered out-patient not covered by medicare, part a. many beneficiaries ask how they can be outpatients. many ask me to change them to in-patient which is something i cannot do. the centers for medicare and medicaid services describ