Medicare Compliance & Reimbursement

Practices that don't have good communication between departments could suffer.

Physicians will have to submit all their information for an appeal at the Qualified Independent Contractor level starting in January. If physicians leave out important documents that could turn the tide, they won't be able to add them after the QIC level.

Until now, providers have tended to wait until they got to the Administrative Law Judge level to submit any additional evidence, notes attorney Alan Reider with Arent Fox in Washington. The evidence physicians submit at the carrier level won't do much good if it's inconsistent with the carrier's policy, but physicians are still better off submitting information to the carrier instead of waiting until the QIC.

Do this: Physicians should be working to improve their processes for gathering medical records and sending them in, says Tammy Tipton, president of Appeal Solutions in Blanchard, OK. If a physician has any "procedural hurdles" to getting all his information together quickly, deal with them now. The physician may need to improve communication between different departments in his office, she adds.

Tip: Make sure all the documentation submitted includes all the information specified by the CPT descriptor as well as the carrier's local coverage determination, advises Deborah Churchill, president of Churchill Consulting in Killingworth, CT. The documents should have the beneficiary's name on each page.

The law further states that if the QICs deny an appeal, they must provide the scientific or clinical evidence they relied on, says Reider. But it remains to be seen whether the QICs will really provide any useful information or feedback for physicians.