Appeals Process Research Articles

The appeal process and beyond (part 3 of 3). When residents shouldn't become clinicians: getting a grip on fair and defensible processes for termination of training.

Training programs have the dual responsibility of providing excellent training for their learners and ensuring their graduates are competent practitioners. Despite everyone’s best efforts a small minority of learners will be unable to achieve competence and cannot graduate. Unfortunately, program decisions for training termination are often overturned, not because the academic decision was wrong, but because fair assessment processes were not implemented or followed. This series of three articles, intended for those setting residency program assessment policies and procedures, outlines recommendations, from establishing robust assessment foundations and the beginning of concerns (Part One), to established concerns and formal remediation (Part Two) to participating in formal appeals and after (Part Three). With these 14 recommendations on how to get a grip on fair and defensible processes for termination of training, career-impacting decisions that are both fair for the learner and defensible for programs are indeed possible. They are offered to minimize the chances of academic decisions being overturned, an outcome which wastes program resources, poses patient safety risks, and delays the resident finding a more appropriate career path. This article (Part Three in the series of three) will focus on the formal appeals and what to do after the appeal.

PNS61 The Second Coming of the Nice Appeal Process?

The National Institute of Health and Care Excellence (NICE) evaluates the clinical and economic impact of new healthcare technologies to inform public reimbursement recommendations. Consultees can lodge appeals to NICE recommendations within 15 days of final draft guidance. These are subject to scrutiny to see if they fall within the grounds for appeal, and if so, an appeal panel is convened. This research systematically evaluated NICE technology appraisal appeals.

A review of evidence supporting NCCN category 2B off-label recommendations for determination of Medicare reimbursement eligibility.

6576 Background: Antineoplastic indications supported by a category 1 or 2A NCCN recommendation are reimbursed by insurance and Medicare, as are FDA-approved indications. While initial reimbursement requests for “off-label” NCCN category 2B indications may be denied, Medicare will reimburse off-label antineoplastic use supported by evidence from a peer-reviewed publication from one of 26 designated journals. Here, we evaluated the published clinical evidence supporting NCCN category 2B indications. Methods: Category 2B drug indications for the 10 most common solid tumor types were identified in the NCCN compendium (n=104). The results were then filtered to include drugs with only category 2B indications in a particular tumor type (n=14). Similarly, FDA-approved indications were excluded, resulting in a list of drugs with only a 2B indication that are not FDA approved in the specified cancer type (n=8). Published clinical studies supporting these category 2B indications were assessed for study type and journal name in PubMed, and journal names were cross-referenced with the CMS-supported list. Results: Among the 8 non-FDA-approved drug indications with only category 2B recommendations, 7 (87%) had at least one publication of a clinical trial in one of the 26 designated journals. The only 2B indication without supporting literature was single-agent gemcitabine hydrochloride in bladder cancer. For further details, see Table. Conclusions: These results suggest that clinicians should consider pursuing the appeals process and provide supporting evidence in cases of claim denial. While coverage is not guaranteed, the evidence supporting 2B indications frequently meets the criteria identified in the Medicare statute. Further studies will evaluate if these findings extrapolate to less common tumor types.[Table: see text]

Does Innocence Matter in Criminal Appeals?

This article examines the importance of innocence in criminal appeals through the lens of Benjamine Spencer’s murder case history and its development through the appeals process. Spencer’s case shows how innocent people can easily be convicted with false evidence and a flawed criminal justice system. Criminal appeals should provide a true path to resolve faulty convictions and fixed flawed aspects of the criminal justice process.

Performance Appraisal – A Source of Employee’s Motivation: A Case Study of Educational Institute of Karachi

The organizational success is largely depending on its employees; they are considered as vital assets for any organization. Therefore, the management should know how to appraise them so that they can get the desired results. The current study aims to investigate the impact of performance appraisal on employee’s motivation in an educational institute of Karachi. The population of interest was permanent faculty, visiting faculty and non-teaching staff of the ABC institute which was selected through convenience sampling technique. A survey of 56 employees was conducted with the help of a questionnaire based on close ended items on a 5-point Likert scale ranging from strongly agrees to strongly disagree. For data analysis, SPSS was used to check the reliability test, descriptive statistics and regression analysis. The research findings provided the insights regarding the impact of performance appraisal on employees’ motivation and showed a positive significant impact. The more satisfied employees are by their appraisals, the more motivated and committed they would be. Moreover, the study also shed light for future direction by keeping in view the respondents concern regarding biasness free rating, feedback and appeal process. The educational institutes should come up with better strategies in order to build trust among employees by providing fair appraisal solely based on their performance.

The extraordinary. Asylum process as an intertextual chain

ABSTRACT The article examines the intertextuality of asylum documents by analysing the links between the documents in various stages of the process. The paper argues that the asylum process materialises in asylum documents and that these documents are inherently intertextual. Thus, they create intertextual chains, that is, they are based on previous documents, which in turn become sources of subsequent documents, thereby creating new links to the chain. The article traces two asylum cases in Finland from the asylum interview to the appeal process while paying special attention to recontextualisation, inclusion and exclusion, assumptions, and absences. The analysis also shows how the inclusions and exclusions can be used in recontextualisation, how the assumptions and absences intertwine with one another, and what kind of consequences these may have for an asylum process. The paper provides an opening in discussing how asylum documents are formed as intertextual chains and how they can be reformed in the process.

For survivors of child abuse, college isn’t just school – it’s a sanctuary

Though child abuse and neglect are an epidemic in the United States, experts estimate that they are grossly underreported, leaving hundreds of thousands of vulnerable children and adolescents at risk for short- and long-term physical and mental health sequelae. Abuse victims may be able to find eventual relief in college, but costs can be prohibitive when colleges expect abusive parents to contribute tens of thousands of dollars to their children’s education. The current piece examines current policies in place for students to request dependency overrides in financial aid and barriers to appealing on the claim of abuse. This piece ends with a summary of recommendations intended to make the appeal process more equitable and favorable for victims.

You Can’t Always Get What You Want: Appealing CMS Enforcement Actions

You Can’t Always Get What You Want: Appealing CMS Enforcement Actions

STORYTELLING CASE STUDY: HOW TO WIN A TAX DISPUTE AGAINST TAX AUTHORITY?

This study focuses on answering five research questions, namely how to understand the background of a tax dispute, how to carry out the tax audit, how to perform the tax audit closing conference, how to run the objection process at the regional level, and how to win the appeal process at Tax Court. This research employed the case study framework as a methodology. The data were collected via interview as well as documentation. The information gathered was analyzed by contextualizing the meaning of the data collected. The result of this research provided insights on winning a tax dispute by implementing several strategies abstracted from the case study.

Understanding the financial impact of a diagnosis of young onset dementia on individuals and families in the United Kingdom: Results of an online survey.

Although literature on postdiagnostic support for people affected by young onset dementia acknowledges financial concerns, this topic has remained underresearched. The aim of this study was to explore the financial impact of a diagnosis of young onset dementia on individuals and families. An online survey, comprising binary yes/no, multiple-response and open-ended questions, was codesigned with people living with young onset dementia. The survey was promoted via networks and online platforms. Data were collected from August to October 2019. Survey respondents across the United Kingdom (n=55) who had received a diagnosis of young onset dementia were aged between 45 and 64, were at different stages of dementia and had been diagnosed with thirteen different types of dementia. Of the 55 respondents, 71% (n=39) had received assistance from family members when completing the survey. The main financial impact of a diagnosis of young onset dementia resulted from premature loss of income and reduced and often deferred pension entitlements. In some cases, care-costs became unaffordable. Lack of clarity of processes and procedures around needs assessments, carers' assessments and financial assessments by different organisations resulted in some families having to ask for legal advice and, in some cases, involved lengthy appeal processes. Future research needs to involve Adult Social Care and Third Sector organisations to help codesign and test financial management interventions to support people affected by this progressive health condition.

Embedding an Advanced Pharmacy Technician in an Adult Specialty Pulmonary Clinic to Complete Prior Authorizations Improves Efficiency and Provider Satisfaction

Purpose: The purpose of this study is to assess the impact of a clinic embedded Medication Assistance Program (MAP) specialist on the prescription benefit prior authorization (PA) process and provider satisfaction in an adult pulmonary clinic. Methods: In this mixed methods study, a retrospective cohort analysis was done to determine the turnaround time for the PA process from initial referral to approval or final denial in an adult pulmonary clinic. Additionally, a pre- and post-implementation survey to providers was conducted to assess provider satisfaction and perceptions around the prescription benefit PA process. The first study aim assessed PA efficiency by summarizing PA approval rate and PA turnaround time using descriptive statistics. Any prescriptions written by a clinic provider requiring a PA during the timeframe of June 2018 through August 2018 were included. The second study aim assessed change in provider satisfaction, analyzed via the Mann-Whitney U test. Results: The MAP specialist completed 110 PAs over 3 months for 110 unique patients. Median turnaround time was 3 hours, with 76% of PAs approved in less than 24 hours. Initial approval rate was 82.7%, and overall approval rate following the appeals process was 87.3%. A significant difference between the pre- and post-survey responses were identified in 2 of the 17 questions. Conclusion: Implementation of a clinic embedded MAP specialist to complete PAs demonstrated an efficient process while also improving provider satisfaction.

Land alienation in the johor bahru district area: the factors of unsuccessful response of form 5a, national land code 1965

Land alienation in Malaysia constitutes an important element in the conduct and governance relating to the National Land Code (NLC) 1965. However, the alienation is within the exclusive jurisdiction of the state authority and the process of such alienation takes too long including to resolve the requirements of Form 5A, NLC 1965. Form 5A is a notice to the applicant to claim the alienation fees which include the quit rent, premium, boundary mark surveying fees, and preparation and registration of documents of title. Although various methods have been taken to manage the issues of Form 5A, there are still lack of response because several internal and external factors. This study investigates the key factors that contribute to unsuccessful of Form 5A in the Johor Bahru District Area. The study conducted by two kind of methods, interviewing 10 respondents and questionnaire distributed to 229 respondents. The results shortlisted 22 factors and narrowed down into four main factors: lack of money, the rates charged are too high, appeal process for premium reduction, extension period and instalment payments. This study is important to balance the property ownership by considering the emerging issues of land alienation for the urban poor.

Stakeholders find that step therapy should be evidence-based, flexible, and transparent: assessing appropriateness using a consensus approach.

BACKGROUND: Step therapy, one approach to utilization management, is used by health plans to ensure safe and clinically appropriate care while managing cost. Several patient and provider groups have each developed principles to guide the appropriate use of step therapy; however, no comprehensive multistakeholder informed set of criteria exist. OBJECTIVE: To assess multistakeholder consensus on criteria for the development and implementation of step therapy for pharmaceutical therapies. Stakeholders were asked to (a) assess the appropriateness of step therapy as a utilization management tool; (b) rate specific criteria across 5 domains (development, implementation, communication, appeals, and evaluation) of step therapy; and (c) categorize these criteria as standards or best practices. METHODS: We conducted a multiphase project culminating in a roundtable of experts representing patient, provider, plan, pharmacy, policy, and ethical perspectives. We first reviewed guiding principles, position statements, and legislative activity to draft criteria regarding step therapy protocol development, implementation, communication, and evaluation. To assess consensus across a convenience sample of experts, we employed an iterative 4-step modified Delphi method. Panelists were asked to (a) rate the overall appropriateness of step therapy, (b) rate the appropriateness of specific criteria, and (c) identify each as a standard or best practice. Appropriateness was rated from 1-9 and categorized in terciles (1-3: not appropriate, 4-6: neither, 7-9: appropriate) to assess quantitative agreement, disagreement, and indeterminate agreement. RESULTS: After the second round of voting, roundtable panelists (n = 16) disagreed on the appropriateness of step therapy for utilization management (50% appropriate, 31.25% neither, and 18.75% inappropriate). Agreement was achieved on 21 criteria across 5 themes (clinical criteria as the foundation for protocol development, implementation of protocols, transparency and communication of processes, navigation of the appeals process, and evaluation of health and administrative impact). Fourteen and seven criteria were categorized as standards and best practices, respectively. CONCLUSIONS: The stakeholders in this panel differed in their assessments of the appropriateness of step therapy but agreed regarding how these protocols should be developed, implemented, communicated, and evaluated. Most criteria were rated as standards that can be used by stakeholders when developing, implementing, and assessing step therapy processes today. DISCLOSURES: This study was funded by the National Pharmaceutical Council. Karmarkar was a fellow at the National Pharmaceutical Council and Duke-Margolis Center for Health Policy at the time this study was conducted. Dubois and Graff are employees of the National Pharmaceutical Council. This work was previously presented as a virtual poster during the AMCP 2020 eLearning Days, April 21-24, 2020.

“Epistemic injustice” in the administration of mental health legislation

ABSTRACT The concept of “Epistemic Injustice” was used as a tool to interpret practices applied during the administration of Mental Health legislation by the Mental Health Tribunal Scotland. This highlighted instances of being wronged on several occasions in my capacity as a knower. Example contributory factors included the Tribunal structure and sub-optimal application of heuristics by panel members. Factors associated with an appeal process involving a “Designated Medical Practitioner” may offer some potential for improvement of routine application of administrative aspects of Mental Health legislation. Testimonial and hermeneutical issues should be considered.

No Free Launch: At-Risk Entry by Generic Drug Firms

After receiving FDA approval, a generic drug manufacturer can launch “at risk” before conclusion of any patent infringement litigation, but it risks paying damages if it loses. The generic can eliminate the risk by waiting to launch until the appeals process is complete but waiting has downsides too. We develop a model that implies that, after the generic has won a district court decision, at-risk entry is generally profitable and will occur quickly unless the cost of waiting for the appeal is very low. We examine generic drug applications that have received FDA approval with “first-filer” status (which precludes later filing generics from entering before the first filer). In our data, the generic and brand usually settled prior to the conclusion of litigation. For the remainder, drugs that received FDA approval prior to a favorable district court decision were always launched at risk. Generics without FDA approval before a favorable district court decision launched upon approval unless the approval was close in time to the appeal decision or it had forfeited the first filer exclusivity (indicating a low cost of waiting). We also consider implications of at-risk entry for social welfare, arguing that at-risk entry is analogous to a “buy out” of the patent with favorable welfare implications in both the short run (consumer prices) and long run (efficient incentives for R&D).

The Economic Consequences of the Opium War

This paper studies the economic consequences of the West's foray into China after the Opium War (1840-42), when Western colonial institutions were introduced in dozens of so-called treaty ports. Among these institutions was the Maritime Customs Service, organizing trade and tariff collection, as well as consular courts that projected Western legal traditions into China. The paper finds, first, that Western countries had a positive impact on China's economy over the 19th century. Regions with Western influence exhibited a higher rate of growth of modern firms and more investment into advanced machinery; moreover, Western influence brought down local interest rates by almost a quarter, with much of this due to Western institutions providing enhanced security and lower risk as opposed to additional capital. Second, both legal and trade institutions contributed to the lowering of risk; firm growth, investment, and technology adoption were closely affected by trade institutions while legal institutions played a stronger role for capital market performance. We also assess individual elements of extraterritorialty in China such as the scope of jurisdiction, appeal process, court proceedings, and sentencing. Third, we demonstrate that the geographic scope of influence went far beyond the immediate vicinity of treaty ports, customs houses, and consulates. Western institutions affected Chinese areas up to 400 kilometers away, influencing a large part, perhaps even the majority, of China during this period.

The Strange Career of the Three-Judge District Court: Federalism and Civil Rights, 1954-1976

The three-judge district court has had a long and strange career in the history of the federal court system. Congress created the court in 1910 as a response to the canonical decision of Ex parte Young two years earlier, which permitted federal court suits against state officials to facilitate constitutional challenges to state laws. The three-judge court statute was a reaction by Progressive Era politicians to such perceived judicial overreach, and required any such challenges to be brought before a specially convened trial court of three judges, with a direct appeal to the Supreme Court available. First established as a presumed limit on judicial activism, decades later plaintiffs in the Civil Rights Era came to see the court as advancing their agenda. Particularly in the South, some plaintiffs preferred to have their suits decided by three judges rather than the usual one, with a direct appeal available to a relatively friendly Warren Court. For that and other reasons, the total number of such cases in the district courts, and direct appeals to the Supreme Court, swelled in the 1960s and 1970s. But at the same time the court came to be seen by many as administratively burdensome and unnecessary, and Congress in 1976 severely restricted the jurisdiction of the court, limiting it to hearing only reapportionment cases. Analysis of the three-judge district court has so far largely relied on anecdotal evidence, and limited empirical studies, to examine whether some plaintiffs in the Civil Rights Era were correct to consider the court as friendly to their interests, as compared to a typical single district judge with the normal appeal process. This article breaks new ground and extends those studies by systematically reexamining these assumptions through a unique, nationwide database of 885 three-judge district court decisions, regarding constitutional challenges to state laws, handed down from 1954 (the start of the Warren Court) to 1976 (when Congress limited the Court’s jurisdiction). The study provides greater and more complete information on the number, types and results of cases litigated in the court, as well as on the dispositions of appeals to the Supreme Court. Among our findings are that such court decisions were disproportionately in favor of plaintiffs, both in and outside the South, and that there was a high rate of appeal to the Supreme Court. We then consider how the decisions of the three-judge court, and its direct appeal mechanism, affected jurisprudential developments in several areas of civil rights litigation, including reapportionment and judicial abstention. We also address how these decisions impact the Judicial Capacity model, which posits that the sheer number of cases that come to the Court for review affects doctrinal developments. The study situates the three-judge district court in a richer historical context, and sheds light on the continued use of the court in more limited contexts to the present day.

The Accidental History of the U.S. Immigration Courts: War, Fear, and the Roots of Dysfunction by Alison Peck

Reviewed by: The Accidental History of the U.S. Immigration Courts: War, Fear, and the Roots of Dysfunction by Alison Peck Michael A. Olivas The Accidental History of the U.S. Immigration Courts: War, Fear, and the Roots of Dysfunction. By Alison Peck. (Oakland: University of California Press, 2021. Pp. 240 pp. Notes, bibliography, index.) Sometimes there are books that leave you much better for the experience. This is one of them. When I retired from teaching immigration law in late 2019 after nearly four decades, I was the most senior such teacher in the country. I had studied immigration law at Georgetown University with Charles Gordon, who was also the general counsel for the Immigration and Naturalization Services. I recall his explaining then how disorganized its structure was, including what my notes called “conflicts of interest that hurt immigrants and the cause of justice.” Alison Peck brought these memories back in her masterful book, The Accidental History of the U.S. Immigration Courts: War, Fear, and the Roots of Dysfunction, which has thirteen chapters in three sections, “Crisis in the Immigration Courts,” “From World War II to 9/11: The Ghost of the Fifth Column,” and “The Future of the Immigration Courts.” Peck is Charles Gordon’s successor in critiquing the Department of Justice (DOJ) and what she calls its roots of dysfunction, showing, for example, how the 1940 assignment of immigration “judges” by the DOJ was compromised by its singular lack of independence and even specific term limits for the judges. In several chapters she reveals the uncomfortable truth that concerns over [End Page 217] various wars, communism, and national security contributed to the jerry-rigged apparatus that exists now, after more than eighty years of existence. What the late John Le Carré treated in fiction, Peck narrates in fascinating and detailed non-fiction prose. Her tour of the topic begins with a chapter called “The Attorney General’s Immigration Courts,” a telling title. Chapter 9, “The Reckoning,” shows that clever media manipulation has deep roots in World War II, and chapter 10, “Un Día de Fuego,” shows that the nomenclature for the Patriot Act, created in the aftermath of the September 11, 2001, terrorist attacks, should have alerted all of us that truth had already become a casualty of war. While Peck’s description of the administrative apparatus that arose and led us to this unsatisfactory situation serves a purpose, her first table (9) clearly reveals how political and dysfunctional immigration courts became during the Trump administration, whose disastrous policies broke the system, exposing its long-established flaws and using them to grind immigration to a halt. Here she shows that during thirteen presidential administrations, from Franklin D. Roosevelt through Barack Obama, there was a total of nineteen “self-referrals,” whereby an attorney general reserved to himself or herself an immigration case that would ordinarily have been resolved by the Board of Immigration Appeals process. She memorably calls this evasion of traditional rules the same as “moving the goalposts midway through a game with life-or-death consequences” (8). President George W. Bush did so ten of these nineteen times. In only four years, however, Donald Trump’s attorneys general moved the goalposts another seventeen times, almost as many as had occurred in the previous seventy-six years. These figures stunned me, despite my career experience. I constantly asked myself why I did not know the scope of all of these finger-on-the-scale events and why it had not been revealed previously in the hundreds of immigration books and articles I have read carefully over the years. This information alone is justification for the book. Alison Peck has dug deeply into impressive archival materials, including presidential libraries and what must have been secretive meetings with those who had access to classified materials and had to remain unnamed. She also has an adept writing style that usefully organizes much complex material into several narratives that synthesize large amounts of data and events. Having narrated her way to the present day, she provides an epilogue that surprisingly focuses on George W. Bush’s retirement artwork in which immigrants are among his subjects, likening them to Lady...

The International Commercial Dispute Prevention and Settlement Organization: A Global Laboratory of Dispute Resolution with an Asian Flavor

The Second Belt and Road Forum for International Cooperation announced the establishment of the International Commercial Dispute Prevention and Settlement Organization (ICDPASO) in 2019. The ICDPASO was coordinated by the China Council for the Promotion of International Trade and the China Chamber of International Commerce, together with industrial and commercial organizations and legal service agencies from over thirty countries and regions including the European Union, Italy, Singapore, Russia, Belgium, Mexico, Malaysia, Poland, Bulgaria, and Myanmar. It was launched on 15 October 2020. As its title indicates, ICDPASO's mandate to provide dispute resolution services is not confined to the Belt and Road Initiative (BRI) countries but includes resolving any disputes that the parties entrust to its jurisdiction. The ICDPASO aims to serve as a “legal hub” to resolve commercial and investment disputes effectively, efficiently, and practically. Unlike other multilateral dispute resolution forums, it is intended to provide an Asian-centric multilateral dispute resolution forum. This essay, the first on the subject of the ICDPASO, discusses how the ICDPASO can serve as a global laboratory for experimenting and innovating in dispute resolution with the potential to impact the landscape of international law, in particular its innovative use of mediation, good offices, and appeal processes to prevent and resolve disputes arising from the BRI. As BRI projects aim to establish infrastructure and digital connectivity within BRI countries and regions for trade and development, this essay argues that the dispute resolution process under the ICDPASO should take into account the overall development of a country or region. The essay concludes that the ICDPASO will be a game changer by introducing an Asian way of resolving disputes.

Automating Employee Appeals Using Data-Driven Systems

In contemporary organizational landscapes, the significance of efficient handling of employee appeals cannot be overstated. Traditional methods of processing these appeals often lead to delays, inconsistencies, and employee dissatisfaction. This paper explores the implementation of data-driven systems to automate the employee appeal process, thereby enhancing efficiency, transparency, and fairness. By integrating advanced technologies such as machine learning, natural language processing, and data analytics, organizations can streamline the appeal submission, review, and resolution stages. The first section of this paper discusses the current challenges faced by organizations in managing employee appeals, highlighting issues such as prolonged response times, subjective decision-making, and inadequate tracking of appeal outcomes. These challenges not only contribute to employee dissatisfaction but can also expose organizations to potential legal risks and reputational damage. The necessity for a systematic and objective approach to handling appeals is thus established. The subsequent section presents a comprehensive framework for automating the employee appeal process using data-driven systems. This framework includes the development of a centralized platform for appeal submissions, equipped with user-friendly interfaces that allow employees to submit their appeals seamlessly. Natural language processing algorithms can be utilized to categorize and prioritize appeals based on their content, ensuring that urgent and significant issues are addressed promptly. Additionally, machine learning models can analyze historical data to predict potential outcomes, guiding decision-makers toward more informed resolutions. A critical component of this automation framework is the implementation of real-time tracking and reporting features. Employees can receive updates on the status of their appeals, fostering transparency and trust in the process. Furthermore, data analytics can provide organizations with insights into trends and patterns in employee appeals, enabling proactive measures to address recurring issues and improve organizational policies. The paper also addresses the ethical considerations associated with automating the employee appeal process. Ensuring that automated systems are free from bias and discrimination is paramount. Strategies for implementing fairness in algorithmic decision-making are discussed, including the importance of diverse training data and continuous monitoring of algorithm performance. Finally, the paper concludes by emphasizing the transformative potential of data-driven systems in automating employee appeals. By leveraging technology, organizations can create a more efficient, transparent, and equitable appeal process that not only meets employee needs but also aligns with organizational goals. The adoption of such systems not only enhances employee satisfaction but also contributes to a more resilient and adaptive organizational culture. This research serves as a call to action for organizations to embrace automation and data-driven decision-making in their employee appeal processes, ultimately fostering a more positive and engaging workplace environment.