Appeals update: Pressure mounts to expand phone demo

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Friday, December 15, 2017

WASHINGTON – CMS is considering expanding a demonstration project to jurisdictions A and B that allows providers to speak with reconsideration professionals by phone to try and resolve their appeals at the second level, stakeholders say.

After hearing testimony from Ronda Buhrmester at a recent Small Business Administration hearing, CMS responded in a letter, saying it “concurs with the noted initial benefits of this demonstration and is in discussions regarding possible expansions to jurisdictions A and B.”

“I feel like, when something is this successful, using two jurisdictions as a control group and not including them is the easy way out,” said Buhrmester, a reimbursement specialist with VGM Group. “This is a way to further reduce the backlog if they want to.”

C2C Innovative Solutions, the Qualified Independent Contractor, kicked off the five-year demo for oxygen equipment and diabetes testing supplies in jurisdictions C and D in 2016. It expanded the demo to other product categories in the two jurisdictions in February and March 2017.

The beauty of the demo: If the QIC issues a favorable opinion on a claim—and it does about 80% of the time—it can analyze similar pending claims at the third level, the administrative law judge, and “remand them back,” says Wayne van Halem.

“The QIC has been able to pull back 47,000 claims from the ALJ so far,” said van Halem, president of the van Halem Group. “The most recent numbers from September show a decline in the number of ALJ cases pending, and I think the QIC demo is a testament to that.”

While the QIC struggled to get providers to participate in the demo initially, that was an education issue more than anything else, says Andrea Stark.

“Providers needed a little hand-holding, because they weren’t familiar with the process,” said Stark, a reimbursement consultant with MiraVista. “But it didn’t take long for them to realize it’s a win-win. If the QIC can reverse it, they will; if they can’t, you don’t lose your place in line.”

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