1). The MAC’s adjudication is the fourth and final  level of the administrative appeals process. In  contrast, SSA officials emphasized to us that responsibility for all  Medicare appeals will pass, under MMA, to HHS on October 1, 2005. To implement MMA’s provisions to transfer SSA’s workload to HHS,  regulations will need to be drafted and finalized by October 1, 2005—the  date that the transfer is required to be complete. Conclusion

SSA and HHS have stressed their commitment to ensuring a successful  transfer of the ALJ level of the Medicare appeals process from SSA to  HHS. Although both agencies have stressed that they are continuing to further  develop details of the plan, based on the information they have developed  thus far, we believe that the plan does not comprehensively address the 13  elements and, thus, seriously jeopardizes a successful and timely  transition. Such significant  deficiencies suggest that a smooth and timely transfer may be in jeopardy. Appendix I: Analysis of the Medicare Appeals Transfer Plan

Based on our review of the plan and additional materials provided by the  transfer team, we found that the plan to transfer the Medicare appeals  function from the Social Security Administration to the Department of  Health and Human Services is insufficient to ensure a smooth and timely  transition. Although the plan generally addresses each of the 13 elements  mandated by the Medicare Prescription Drug, Improvement, and  Modernization Act of 2003 (MMA), as indicated in figure 2, it omits  important details on how each element will be implemented. Furthermore,  the plan overlooks the need for contingency provisions, which could prove  to be essential, should critical tasks not be completed in a timely manner.
Why GAO Did This Study

The Medicare appeals process has been the subject of widespread concern in recent years because of the time it takes to resolve appeals of denied claims. Two federal agencies play a role in deciding appeals--the Department of Health and Human Services (HHS) and the Social Security Administration (SSA). Currently, neither agency manages and oversees the entire multilevel process. In the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Congress mandated that SSA transfer its responsibility for adjudicating Medicare appeals to HHS between July 1, 2005, and October 1, 2005. In addition, it directed the two agencies to develop a transfer plan addressing 13 specific elements related to the transfer. GAO's objective was to determine whether the plan is sufficient to ensure a smooth and timely transition.

What GAO Found

Transferring the Medicare appeals workload from SSA to HHS requires careful preparation and the precise implementation of many interrelated items. The transfer is mandated to take place no later than October 1, 2005. SSA and HHS have stressed their commitment to ensuring a successful transfer of the administrative law judge (ALJ) level of the Medicare appeals process, and both agencies have emphasized that they are continuing to further develop details of the plan. Although the plan generally addresses each of the 13 elements mandated by MMA, it omits important details on how each element will be implemented. Furthermore, the plan overlooks the need for contingency provisions, which could prove to be essential, should critical tasks not be completed in a timely manner. GAO believes that this essential information is needed to facilitate a smooth and timely transfer. Its absence makes it unclear how the transfer plan will be implemented and threatens to compromise service to appellants.