Medicare moves to speed up appeals process

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Sunday, October 24, 2004

October 25, 2004

WASHINGTON - Medicare has taken a key step to help beneficiaries resolve their appeals more quickly and efficiently, as part of a comprehensive overhaul of the Medicare claims appeals system, CMS Administrator Mark B. McClellan, M.D., Ph.D., announced last week.
CMS awarded contracts to eight Qualified Independent Contractors (QICs) to perform reconsiderations, or second level claims appeals, of denied Medicare fee-for-service claims.
"Seniors and people with disabilities deserve a prompt and consistent and responsive process for their claims appeals in Medicare," McClellan said.  "We are working toward completing our overhaul of the Medicare claims appeals system by Oct. 1, 2005 to better serve Medicare beneficiaries, providers, physicians, and other health care providers."
The reconsiderations that will be conducted by the new QICs will replace the current "fair hearing" process for Medicare Part B claims and establish a new second level of appeal for Medicare Part A claims.  Statute requires that reconsiderations must be completed within 60 days from the day the request is filed.
The eight entities selected were:
1     Integriguard, LLC;
2     Q≈ Administrators (Q≈A);
3     Island Peer Review Organization (IPRO);
4     Rivertrust Solutions, Inc.;
5     Computer Sciences Corporation (CSC);
6     Maximus, LLC;
7     First Coast Service Options, Inc.; and,
8     Permedion.
As part of the new process, the contractors will be able to bid on specific types of appeals workloads such as Part A, Part B or durable medical equipment, and in the specific areas of the country for which they will process claims.
Other steps that CMS is taking as part of its comprehensive overhaul of Medicare claims appeals include:
*     Finalizing the transfer of responsibility for the third level appeals conducted by administrative law judges from the Social Security Administration to the Department of Health and Human Services by Oct. 1, 2005.
*     Developing a new appeal-specific data system that will allow authorized users to track individual appeals in real time.
*     Establishing an administrative QIC that will oversee the distribution of case-files, develop appeals processing protocols, conduct training of the QICs, and the dissemination of information on QIC appeals decisions to the public.
*     Implementing a 60-day decision deadline and improved notices for claims redeterminations, or first-level appeals performed by fiscal intermediaries and carriers. The improved notices will include the specific reasons for the decision and a summary of relevant clinical or scientific evidence used in making the decision.
*     Issuing the final regulations needed to implement the new uniform appeals procedures, including the rules QICs and other appeals entities by the end of the year.

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