Earlier this month, the Office of the Inspector General (OIG) released a report titled, “The First Level of the Medicare Appeals Process, 2008-2012: Volume, Outcomes, and Timeliness”.
According to the OIG, the Medicare appeals process serves as an important protection for beneficiaries and providers. Their study represents the first examination of redetermination, i.e., the first level of the appeals process for Medicare Parts A and B. This study contributes to OIG’s body of work concerning the Medicare appeals system. This study focused on redeterminations processed for Medicare Parts A and B during 2008–2012.
The study found that in 2012, contractors processed 2.9 million redeterminations, which involved 3.7 million claims, an increase of 33 percent since 2008. Although 80 percent of all redeterminations in 2012 involved Part B services, redeterminations involving Part A services have risen more rapidly. By 2012, appeals involving recovery audit contractors accounted for 39 percent of all appealed Part A claims. Contractors decided in favor of Part A appellants at a lower rate than that for Part B appellants.
Also, contractors largely met required timeframes for processing redeterminations and paying appeals decided in favor of appellants, but they fell short of meeting timeframes for transferring case files for second-level appeals. In addition, contractors use information from redeterminations in a variety of ways to improve their operations and to educate providers.
Finally, CMS employs multiple methods to improve contractors’ processing of redeterminations, including fostering communication among contractors and implementing the Medicare Appeals System (MAS) for first-level appeals.
The OIG recommends that:
- CMS uses the MAS to monitor contractor performance
- CMS continues to foster information sharing among Medicare contractors
- CMS monitors the quality of redetermination data in MAS
CMS concurred with all three recommendations.