Not so QIC

C2C launches demo to resolve claims at the second level of appeals, before they escalate to the ALJ
Friday, March 11, 2016

JACKSONVILLE, Fla. – Certain HME providers will now have a voice at Medicare’s second level of appeals as part of a new demonstration project.

C2C Innovative Solutions, Medicare’s Qualified Independent Contractor or QIC, has launched a demo project that allows providers in Jurisdictions C and D to speak with a reconsideration professional by phone to try and resolve their cases.

“This is the first real solution that anyone has brought forward that could potentially have an impact on reducing the tremendous backlog at the administrative law judge level,” said Wayne van Halem, president of the van Halem Group.

The QIC will randomly select up to five claims per National Provider Identifier or NPI for diabetes testing supplies and oxygen equipment, and then notify providers by mail with a scheduled date and time for a phone conversation.

Until now, providers had to wait until the ALJ, the third level of appeals, before the process became more than just reviewing the same paper trail of documents, stakeholders say.

“For providers, going through redetermination (the first level of appeals) and reconsideration (the second level) feels the same, because they’re shut out and can’t talk to anybody,” said Andrea Stark, a reimbursement consultant with MiraVista. “It’s a different dynamic at the ALJ and that’s why we see the great reversal rate at that level.”

Stakeholders say opening up a dialogue with the QIC will likely result in more reversals at the second level and fewer appeals escalating to the ALJ.

“I do feel like there’s great potential for that to happen,” Stark said.

If the QIC sides with providers on the initial claims, it will then consider appeals for other similar claims dating back to Jan. 1, 2013, including those stuck at the ALJ.

“I’m assuming that there are a lot of cases from 2013 that are just sitting at the ALJ and have been for some time,” van Halem said.

Based on conversations with officials from C2C, stakeholders believe the demo project will be expanded to other jurisdictions and other product categories.

“That’s the ultimate goal,” Stark said.

Providers that are invited to participate in the demo project should jump at the chance, but they need to keep one thing in mind, stakeholders say.

“The contractors are bound by the policies,” van Halem said. “This is not something where providers can argue the relevance of the policies. Providers need to respect that.”