Part B Insider (Multispecialty) Coding Alert

Published on Sat Jun 28, 2008 PDF

54 percent of QIC appeals included wrong information

If you-ve been relying on the Medicare Qualified Independent Contract (QIC) program to take care of your appeals in a timely fashion, the OIG has bad news.

Two years ago, CMS changed the appeals process, ensuring that you-ll first appeal a claim to your carrier, followed by filing a reconsideration appeal to the QIC, and then if that doesn't pan out, you can appeal at the administrative law judge (ALJ) level.

Although the new process constituted a change to the way practices were used to appealing, some analysts were relieved that the streamlined approach instituted requirements not only for practices, but also for the government.

For example, the contractor or QIC must make reconsideration decisions at the first and second appeal levels within 60 days, while the ALJ has 90 days to make a decision.

However, a new OIG audit of the QIC process indicates that although you-re still expected to stick to your end of the bargain, more than half of the QICs are not quite as precise in dealing with deadlines.

The OIG found that overall, 58 percent of Part B QICs did not pro-cess claims within the 60-day timeframe, while one particular Part B QIC failed to process the claims on time in nearly three-quarters of the reconsiderations it processed.

Plus: The QIC claims processing personnel entered inaccurate information into the Medicare Appeals System in 54 percent of reconsiderations. These mistakes ranged from listing inaccurate appellate types to wrong decision dates.

"What's disturbing about the OIG's findings is that often, they don't tell you your appeal is going to be delayed," says Heather Corcoran with CGH Billing. "This can cause problems down the road because if the QIC denies your claim, you still face deadlines at the ALJ level and you don't want to fall behind."

Take action: One way to stay on top of the appeals process is to track the 60 day period on your calendar, and follow-up when the QIC falls behind, suggests Quinten Buechner, M.S., M.Div., ACS-FP/GI/PEDS, CPC, CCP, CMSCS, with ProActive Consultants, LLC in Wisconsin.

To read the OIG report, visit http://oig.hhs.gov/oei/reports/oei-06-06-00500.pdf.