The Civil Remedies Division

The Civil Remedies Division (CRD) provides staff support for the ALJs assigned to the DAB. The ALJs are qualified under the Federal Administrative Procedure Act to conduct hearings on the record. Generally, the ALJ decision is an initial decision that may be appealed to the Board. If the ALJ decision is not appealed, it is the final administrative decision.

CRD ALJs hold hearings in which parties may challenge the following types of actions:

• fraud and abuse determinations by the Office of the Inspector General (OIG) or the Centers for Medicare & Medicaid Services (CMS);
• provider/supplier enforcement and certification determinations by CMS;
• terminations of or refusal to grant or continue federal funding for alleged civil rights violations;
• Program Fraud Civil Remedies Act determinations;
• civil money penalty determinations by SSA;
• equal Access to Justice Act determinations relating to OIG proceedings.

CRD ALJs also provide hearings and issue initial agency decisions regarding civil money penalties proposed by CMS under the Health Insurance Portability and Accountability Act of 1996. These ALJ decisions may be reviewed by the CMS Administrator or his or her delegate. CRD ALJs also conduct hearings to review Local Coverage Determinations promulgated by Medicare contractors (including fiscal intermediaries and carriers). In addition, CRD ALJs provide hearings in certain debt collection cases brought by SSA, involving nonbargaining unit employees and debts, requiring an independent hearing officer.

Nature of the Caseload

The jurisdiction of the Division's ALJs includes appeals from civil monetary penalties (CMPs) and other enforcement actions taken by the Centers for Medicare and Medicaid Services (CMS) against nursing home providers, clinical laboratories, home health care agencies and other health care providers. Actions taken by Peer Review Organizations may also be appealed to the Division. In addition, the judges decide cases regarding exclusion actions and civil monetary penalties imposed by the DHHS Inspector General (IG) involving individual and other health care practitioners, as well as the EMTALA or "anti-patient dumping" cases. Medicare beneficiaries may also seek CRD ALJ review of Local Coverage Determinations promulgated by Medicare contractors (including fiscal intermediaries and carriers). Also within the Division's jurisdiction are certain CMP actions taken by the IG for Social Security Administration. The division has a variety of other jurisdictions, including claims collection and certain Civil Rights and HIPAA cases. At this time, the majority of cases involve CMS sanctions against nursing homes. The second most significant caseload involves the DHHS IG exclusion cases.