OIG study: Appeals process lacks clarity, consistency

Thursday, November 15, 2012

WASHINGTON – The Office of Inspector General (OIG) recommends “coordinated training” for administrative law judges (ALJs) and qualified independent contractors (QICs) on the Medicare appeals process in a new report. The OIG has found that the ALJs, which administer the third level of appeal, reversed 56% of the decisions by the QICs, which administer the second level of appeal. This trend, according to the OIG, is due to different interpretations of Medicare policies and other factors. The OIG found that when CMS participated in appeals, ALJ decisions were less likely to be favorable to appellants. The OIG recommends, among other things, that the Office of Medicare Hearing and Appeals and CMS provide more coordinated training on Medicare policies for ALJs and QICs, and that they identify and clarify Medicare policies that are unclear and interpreted differently.