Informal Agency Action
The vast majority of agency actions are done informally. For example, every claim for payment for medical treatment rendered to a Medicare patient requires agency action. There must be a determination that the care was rendered by a provider entitled to payment, that the care was necessary and proper, and the amount that should be reimbursed for the care. These must be resolved in a more efficient way than an agency hearing, or the system cannot function. Medicare does this by setting out specific objective criteria for payment, many of which are set out in the Conditions of Participation, and they contract with private companies to check claims against the criteria. Many of the requirements are assumed to be met, such the requirements for medical record keeping to support the claims. Although these are not checked on an ongoing basis, they are subject to audit. If the auditor finds that there is not appropriate documentation, then past claims can be disallowed and the provider required to provide a full medical record with every claim.
Agencies may also use what are termed “grid” or “matrix” regulations, meaning that there is set of criteria, often set out in the table—hence the name—for eligibility for a particular government benefit, such as a disability claim. The claims examiner just checks off the information in the application for benefits to see if it meets the criteria. If the application is denied, the agency provides an appeal process, which usually culminates in a hearing before an ALJ. This gives the applicant the opportunity to provide additional information or to argue that the grid regulations are inappropriate in the specific case.