Medicare Compliance & Reimbursement

Expert fret over rule change that may damage appeal chances.

Under the new appeals system, adjudicators don't want to see the appealing provider's face much - and that's probably not good for an appeal.

The Centers for Medicare and Medicaid Services has set out a new appeals system featuring the qualified independent contractors and speedy new timelines for decisions. The system already has taken effect for rehab providers providing services under Part A providers and will phase in appeals for outpatient services provided under Part B on Jan. 1, 2006.

Don't Count on a Live Hearing

The new system reduces a provider's chance of putting its case in front of a live adjudicator, legal experts note. For example, the second level of appeals for rehab providers currently is the fair hearing officer, and the hearing can occur in person. But starting in January, the QIC will take over the second level of appeals and will conduct on-the-record reviews only.

And most administrative law judge hearings historically have been conducted in person. But under the new system, now that the ALJs are under the Department of Health and Human Services, rather than the Social Security Administration, teleconference hearings are the norm. Providers will have to waive their right to a 90-day decision if they wish to conduct an in-person ALJ hearing.

The ALJ change is partially due to the fact that HHS plans only three field offices and a headquarters for the whole nation. Prominent lawmakers have challenged the move, but cost concerns are likely to trump ethical objections about in-person versus video hearings.

Providers' Hands Tied in On-The-Record Hearings

Providers will face their first challenge in the on-the-record hearing at the QIC, says attorney Denise Fletcher with Brown & Fortunato in Amarillo, TX. "When it's all on the record, it's a lot harder to get ideas across," Fletcher says.

For example, providers can't point to a certain line on a claim or in a policy, Fletcher protests. And providers fear QIC reviewers will fail to take the time to read physician progress notes carefully.

Also, live witnesses cannot testify on a provider's behalf at the QIC, points out attorney Lester Perling with Broad and Cassel in Ft. Lauderdale, FL. That means the appealing party loses out on the credibility an in-person explanation can bring to the matter.