Medicare Compliance & Reimbursement

New 'QIC' step could bring quicker objective review.

Medicare is again tinkering with its appeals processes, and, surprisingly, one of the upcoming changes could benefit providers.

The appeals change adding a qualified independent contractor (QIC) step has been a long time coming. Congress passed the step along with other appeals changes in the Benefits Improvement and Protection Act of 2000 (BIPA).

The Centers for Medicare & Medicaid Services will contract with at least four QICs to process the second level of Medicare appeals, the Government Accountability Office explains in a new report (GAO-05-45). The first level of appeals is at the contractor level, while the third is the ALJs and fourth the HHS Medicare Advisory Council.

BIPA called for QICs, along with a number of other changes, to be in place by October 2002. But CMS issued a notice in the Oct. 7, 2002 Federal Register saying it couldn't implement many of the provisions, including the QIC appeals.

"This regulation is long overdue," notes William Dombi, vice president for law with the National Association for Home Care & Hospice's Center for Health Care Law. The QIC will add a second level of appeals for Part A claims and replace the fair hearing officer appeal for Part B claims, the GAO report explains.

More-Independent QICs Are Good News For HHAs

Unlike fair hearing officers, QICs will contract directly with CMS instead of the Medicare contractors that adjudicated the claims under review, notes Lester Perling, attorney with Broad and Cassel in Fort Lauderdale, FL. That may lend QICs more independence than fair hearing officers have, Perling hopes.

Currently, home medical equipment suppliers are rarely successful in front of fair hearing officers but often successful in front of independent ALJs, notes attorney Jeff Baird with Brown & Fortunato in Amarillo, TX. Replacing fair hearing officers with independent QICs "could be a real plus," Baird predicts.

Home health agencies also are rarely successful when appealing decisions at the intermediary level, Perling notes. QICs may work more in their favor as well.

CMS itself has said it expects the ALJ workload to drop once QICs are in place - presumably because QICs will return more favorable determinations to providers.

But whether QICs will be a boon to home care providers is up in the air, cautions Ann Howard with the American Association for Homecare. Forthcoming details on who the QICs are, how they are trained and what guidelines they must abide by will make the difference, Howard predicts. 

The GAO urges the Department of Health and Human Services to implement its appeals requirements, or at least draw up contingency plans if HHS and CMS can't manage implementation by October 2005. Other BIPA requirements chiefly involve shortening appeals timeframes.

Downside: Along with the good appeals provisions from BIPA will come some burdensome ones. That includes expedited appeal rights to beneficiaries whose home care services are terminated, Dombi notes. Benes will be able to obtain a reconsideration within 72 hours, which means HHAs will have to hustle to pull records together for the review.

Another unfavorable appeals provision passed in the Medicare Modernization Act last December could be in effect right now, Perling says. MMA said providers would have to present all evidence at the QIC level of appeals starting Oct. 1. But because the statutory language specified the QIC level, ALJs may accept new evidence because QICs have yet to be set, he notes.

Nonetheless, HHAs should play it safe and introduce all relevant evidence at the contractor appeal level, Perling advises.