Medicare Compliance & Reimbursement

If you've been relying on the Medicare Qualified Independent Contractor (QIC) program to take care of your appeals in a timely fashion, the OIG has bad news.

Two years ago, the Centers for Medicare & Medicaid Services changed the appeals process, so that you first appeal a claim to your intermediary or carrier, followed by filing a reconsideration appeal to the QIC, and then if that doesn't pan out, you can appeal at the administrative law judge level.

Although the new process changed the way providers were used to appealing, some analysts were relieved that the streamlined approach instituted requirements not only for providers, but also for the government.

For example: The contractor or QIC must make reconsideration decisions at the first and second appeal levels within 60 days, while the ALJ has up to 90 days to make a decision.

However, a new HHS Office of Inspector General audit of the QIC process indicates that although you're still expected to stick to your end of the bargain, more than half of the QICs are not quite as precise in dealing
with deadlines.

Part A QICs met their appeals deadlines fine, the OIG says in a new report. But Part B QICs did not process 58 percent of cases within the 60-day timeframe, and one particular Part B QIC failed to process the cases on time in nearly three-quarters of the reconsiderations it processed.

Plus: The QIC claims processing personnel entered inaccurate information into the Medicare Appeals System in 54 percent of reconsiderations. These mistakes ranged from listing inaccurate appellate types to wrong decision dates.

"What's disturbing about the OIG's findings is that often, they don't tell you your appeal is going to be delayed," says Heather Corcoran with CGH Billing. "This can cause problems down the road because if the QIC denies your claim, you still face deadlines at the ALJ level and you don't want to fall behind."

Take action: One way to stay on top of the appeals process is to track the 60-day period on your calendar, and follow up when the QIC falls behind, suggests Quinten Buechner with ProActive Consultants in Wisconsin.

Meanwhile, CMS has awarded three new Part B QIC contracts since the time period the OIG studied, the agency says in comments responding to the report. Those contractors have processed 98 percent of appeals on time, it contends.

Note: To read the OIG report, visit http://oig.hhs.gov/oei/reports/oei-06-06-00500.pdf.