Departmental Appeals Board

CIVIL REMEDIES DIVISION OVERVIEW

Organization of the Division

The Civil Remedies Division is composed of Administrative Law Judges (ALJs), including a Chief ALJ, and a support staff composed of attorneys and paralegals. The ALJs are qualified by the Office of Personnel Management and selected by federal agencies to serve as independent decision-makers. They conduct hearings, decide cases and issue decisions.

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. 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.

Case Resolution and Hearings

Appeals before the Division are resolved in various ways, including voluntary settlement by the parties, on-the-record submissions, or in-person hearings. Hearings are adversarial and may involve expert testimony. The proceedings are transcribed and typically followed by posthearing briefing. Although the Division is headquartered in Washington, DC, the ALJs and staff travel to locations throughout the United States to conduct hearings. The ALJs determine the time and place of the hearing; every effort is made to select a location which accommodates both parties. Decisions rendered by the Division's ALJs may be appealed to the Departmental Appeals Board and subsequently to the federal courts.

Regulations and Procedures

In general, the regulations governing cases in which CMS is a party are found at 42 CFR 498; the regulations governing cases in which the Inspector General is a party are found at 42 CFR 1005. Certain procedural guidelines issued by the Division may impose some additional requirements. Although the rules for both of these caseloads are similar in a number of respects, there are some notable differences. It is important when litigating a case before the Division to review and be thoroughly familiar with the specific regulations governing the case at hand, and its accompanying procedures.