To air in favor of saying okay we are going to this with you. At some point i wonder whether we have diminishing returns here. Thats more of a provocative question rhetorical question at this point. But i do think that constructs probably should urge us to think about whether its the way we should be doing these appeals. I would like to clarify one thing. He said the percentages you are looking at are on their recovery audit appeals. And the reversal rates on those appeals have been higher than the general reversal rate for the agency which as you know includes all appeals. So for 2014 and again the numbers i have are fully favorable decisions, that it was just 19. 3 . The numbers have been im sorry, that was fully favorable. I keep going to that number. I will get you a number on the reversal. Everything ive been told is that when cms is actually present at these hearings, that decisions are not made but the cms representative is oftentimes not present. So that suggests to me again that we have a system that isnt operating properly. We want fairness across the entire sectors so one provider shows up, has their appeal and cms person shows up and its not sustained another provider shows up in the same sort of circumstance that the cms person is not there and it is the same. We are not providing equal protection under the law. What we have found, and there is very limited data on this. It does come from cms but when there is cms participation at the hearing the reversal rate does go down. By how much . Do we know . I think its about 6 if i remember correctly. Its only over a few months of data that we have. I will get you the exact numbers but from about 46 down to 40 . Yeah 40 . As far as the reversal rates, i have got that number now which is on the disposition, the overall, the overall favorable rate is 32point 5 . We have been doing a number of things which have been designed to bring our policy interpretations in line across all levels in consistency and adjudication. Part of that is training and we have 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 Data is that the reversal rate has actually been going down. They were at a highend in 201055. 5 fully favorable and that is now down to 35. 2 . Why . I think the training efforts have a lot to do with that. A better quality decision because we are dealing with every case in front of them and they have to make a decision so the question is the case is coming to you they either made better decisions at a lower level or their something that has happened at the alj level with better training that you are making better decisions and the decisions earlier he were finding feet people fully favorable more often than what would be policy. For the joint adjudication level. That would still mean at some point you have to make fully favorable decisions or partially unfavorable. That would save there was an issue at some point you are doing too many fully favorable. I dont know if i would go so far as to say we fix them but i would say it has improved it and i think as congresswoman speier points out the goal is to have the case paid if it is a validly visible claim to have been paid early in the process as possible and keeping them from reaching the alj level. Mr. Chairman matt ask a question . I just want to touch on this. Is the training coming from you to alj backed up to cms, feedback that is cms and accepting that as a direct out of . Im going to use an example thats happening in the orthotics and prosthetics industry where after an artificial limb is made and delivered to the patient the claim is being denied by audit because the actual words patient is an amputee does not appear in a physicians notes. But the words patient requires audit artificial limb appear and the medicare history includes payment for the surgeon to conduct a limb amputation. And so many of these denials could be eliminated if, and getting a reverse on the alj. Is there feedback going back down to the cms saying just because the exact words do not appear in the surgeons note that the patient is an amputee doesnt mean that you deny these because if you look it says the physician is saying they need a prosthetic and we pay them to a limb. Are you looking at different records . Because you know. Nell no as a general record we review the record and there are some exceptions to that which allows additional representatives at the alj level that we are supposed to be designing things on the same record. What does change significantly is we do have a hearing and so at our level we are able to question the provider supplier, receives some explanation and then make a decision that becomes part of the evidence thats in front of us. My understanding is that the editors are not allowed to consider their professionals notes that those notes are considered part of the physicianss record and may show up under the physicians record so the person who makes the artificial leg, iraq auditors are not allowed to look at his nose. They only look at the physicians notes that when you look at the physicians know to look at it in the entirety which includes the notes. Is there feedback coming to you from cms to allow iraq auditors at the lower level to say you need to look at the processors notes because you are pushing them through the system and its ridiculous when someone is being you know, something as simple as patient is an amputee is missing from the record of a guy who we have paid already to have his leg amputated . We have regular meetings with cms and their appeals grade within cms. I think those happen on a weekly basis, a weekly basis. When we identify a trend, we would bring that up at those meetings or if it was a significant trend i would bring it up. Im not aware of the specific instance that you are describing. Its more than one. We have 100 auditors in this country who have gone out of business waiting to be reimbursed and have gone out of business. I am sure we can get you a lot of those examples. We have been aware of them. I think thats part of the issue. Our judges are 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 . Do have a system in place at the alj level to find those trends and i think its another. I just want to reiterate the woman from alumni, she is exactly right. This is not just unique to her particular group. We have physicians who literally go through step one and step two that have complete records and it has to go to you before you look inside oh god is a complete record and they waited many months or years to find it. And its crazy stuff ms. Griswold. I have examples i mean 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 is at the bottom or the physician had signed his name in this spot and i know we cant fix stupid but it seems like thats what we have got to do. I mean its a reasonable person would do this and you talk about trends. I dont know how you define trends because you have adjudicators that are adjudicating across the omaha system. So what one adjudicator is seeing is a trend in his or her jurisdiction. It doesnt work so i appreciate the javelin wielding and i yield back. I just have one final thing and that is, as you go to meet with the newly confirmed secretary burwell i was hoping that you would consider having a conversation with her about granting the same kind of relief from iraq audits that would feedback to the hospitals under part a under the part b providers like those in orthotics in prosthetics. I think we need to consider putting it under part b especially since theres a hault to the hearings at this point. Thank you mr. Chairman. Ms. Grissom would you like to jump in . Thank you mr. Chairman and at the risk of quite frankly piling on in the last couple of comments and statements, i have the same concern. I applaud that you have introduced new initiatives so your productivity is better but now we are minimizing as my information says that the average hearing is now two hours and given the complexities we havent talked about the complexities. We have talked about the easy stuff. Im not sure it gets addressed in and while i know given we now have an incredible backlog and we are struggling with that, its time to do more than figure out the steps, how we are across communicating and what the training looks like. We have to do something upfront in the up trend is nobody on this committee and i dare say no one in congress is willing to tolerate waste abuse and fraud. Everyone in the system to do everything we cannot just to minimize it to eradicate it. These are clearly administrative issues and while i do expect providers to be as administratively competent as they can, i cant do with consistency, and im a lawyer, even read a medicare dob. Given the likelihood that you make mistakes simple, the form says that the date at the bottom of the form is updated this year and ive got 200,000 forms from last year. Instead of throwing those away, and no one pays attention to that. The fact is we are doing this under a waste fraud and abuse context and i think thats important but we are closing the businesses who arent going to be paid and theres a lot of small providers. Again i know you have heard all this and we appreciated and i agree with my colleague. I want fairness. Just because you are a big provider i dont think at that Hospital System should have to wait and be penalized in this fashion. But what is critical in a frontier state like mine of new mexico that means an entire Community Aware and one of my districts in Torrance County there arent any providers. There arent any durable medical provider equipment. They are done. There is zero access. We dont even have the right tools or strategies to recreate these practices. So im really interested in the results of understanding now the situation between how they are adjudicated, what your initiatives are, how you were trying to manage these cases. I appreciate the weekly meetings but i would encourage you to go back to the secretary and be really clear on some of these comments and it seems like we are all on the same subcommittee. We have a problem on the front end, so we do want, at least i do want information you are doing on the backend and i want to be careful because its cumbersome that we can win on appeal even though there might be a material problem. But i think the bulk of these cases and the reason you have half a million cases coming on appeal is because they are administrative issues that dont come anywhere close to fraud, waste and abuse. We need to deal with that issue sooner than later. I dont know if theres a comment to make back but my expectation that youll take this urgency back because with all the work we have done to maximize access, this effort is minimizing it to the highest degree. And it has a Chilling Effect on our patient population. I would certainly take that back and if there is a positive bed is coming out of this situation i think it is that the department is viewing this workload more holistically although there are three separate agencies, cms, omaha and the department that deals and department of his Appeals Council that work with the spec was. The department is taking an active role in trying to resolve things and so i will take your concerns that. I certainly share them. I would also say i was very pleased when i came here to omaha to be part of an agency that has for the most part met its 90day timeframe. As an administrator myself i find the delay very troubling and unacceptable. You basically have here a workload capacity problem. You may get to that for a moment . We can sit here and complain for hours. Nothing is going to change because the addition of 17 new aljs, talk about the simple math that my good friend mr. Meadows had referenced, there is 500,000 of appeals that will be backlogged by the end of this year. If you divide that by 1220 and i dont know you could do any more than that and frankly i dont know if we would want to do more than that because less than two hours is probably unfair and would be that would suggest that we would need 410 new alj if we wanted to get rid of that backlog. 410 and you have asked for 17 or you have given 17. We are basically saying to the providers out there to up. Excuse my language but thats basically what we are saying to them. We are saying that we are not willing to deal with this backlog in the reality that putting blinders on and well add a few more and cross our fingers and hope that with a few new reforms that you put in place, but its not going to reduce it to the extent that we are not going to be back here next year with the same discussion. So how would you comment to that . While there are several things. One. Am sorry to intrude. Can you bring your mic a little bit closer to you . Sure. Thank you. There are several funding issues here and in my mind one of the primary ones had to do with the Recovery Audit Program and recovery audit legislation. I think when Congress Passed the legislation for the program we envision that program would be funded out of recoveries that the legislation actually provides that the administrative cost of cms will be covered. That does not include the administrative costs or of omaha or the administrative cost to the departmental appeals board. But we have basically had in that regard is a workload that came in on us that was basically unfounded. So i think thats part of the problem and is 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 fixes that i think would be possible. Meaning what . In some ways able to properly fund, to find omaha and i will put in a plug for my Sister Agency the departmental appeals board so the recovery audit appeals that come to last two levels are funded under the administrative costs are funded out of the program and they are at the lower two levels. Is there enough money that is recovered by the rack to pay for all of the levels of the appeals . Yes, i think that there is. This is based on cmss reports on the recoveries that are coming from that program. So that is one part i think of the solution. There are some other things as well. We are doing these two pilots. One involves alternate adjudication models using a settlement facilitation. If that pilot is successful i think we need to look at Something Like that as well. Is that being piloted in a geographical location . Its being piloted at the office of medicare appeals. Theres no geographic location. Its being done with part b i believe, part b claims right now. There is a certain time period where we are offering these facilitated conferences. Give us an example of what that means. Reallife terms. Reallife terms it was put on our web site on june 30 so its a very new program and we are waiting to see how appellants respond to it. But the theory is that an appellate will be able to come and ask for a settlement conference with an attorney who is in omaha. Cms would provide someone with a Settlement Authority who would be able to discuss the claim impossibly resolve them having to stay at the hearing. That is the theory. While that is going on they do not lose their place in the hearing q. So they would still remain there but we are hopeful this would allow us to solve several pending claims. This is a twopart problem. Theyre the pending claims we have and also the receipts that are coming in. This piece of the solution is designed to deal with the pending cases that are already with us. Is that your assumption that the cases in the settlement process back to mr. Meadows mr. Meadows statement is not at the top, its at the bottom. Its right here. Is it your assumption that will be that kind of stuff coming at you or the assumption with the settlement and are these settlements are lesser amount or as a fully paid at a faster processing and full payment . Well i think it depends. Like most settlement conferences its going to be probably a little bit of give and take. That would be my anticipation but if its something, in the course of what really a conference with an attorney point out a simple error, a technical error or Something Like that in these claims then you know it is potential. It is possible that they would be fully paid. We just have to wait and see how that would work. And alternative dispute resolution would be viable to providers in particular if it was a decision that was going to be made swiftly. Yes. And that becomes the appeal. We are trying to find ways. No pun intended. We are trying to find ways in our our work work work load more quickly than we can get them to an alj and we are trying to do that given our current authority. Right now the way the statutory scheme is structured and appeal cannot get out of step three. It cannot leave omaha without an alj. What this would do, there would be this agreedupon 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 its 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 cmss initiatives and i have to admit that my knowledge on this is limited. Its 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 havent seen it operational yet. No we have not. Its an initiative that is still pending. I know you are communicating back and forth of cms and seamus is part of the issue and they get that thats not you but there is very little conversation. Thats really something they would have rather had with cms and to get this done a long time ago facetoface with some of their and would have been able to get on the phone with the same document try to resolve this. Simple straightforward cases, they just want this resolved. If they are a physical therapist that is trying to take take care of its practice as well as do all the paperwork he needs one more thing to do to chase the stuff down. Just be able to be in the process or to hire outside counsel is well beyond what they want to do based on the resolution. How could a process like what you are experimenting with working with cms so it never gets to you, we are still trying to figure out how to prevent the backlog. I think among cmss initiatives you will see mention of the discuss