Medicare Sees 33% Spike in Claims Appeals

John Commins, for HealthLeaders Media , October 7, 2013

Maddaloni said the study represents OIG's first examination of the first level appeals process for Medicare Parts A and B. The study focused on redeterminations processed from 2008-2012. The study analyzed the Centers for Medicare and Medicaid Services' Contractor Reporting of Operational and Workload Data system. OIG auditors surveyed 18 contractors that process redeterminations for Medicare Parts A and B and interviewed five RACs to learn more about how they process redeterminations.

While contractors generally met mandatory timeframes for processing redeterminations and paying appeals for successful appellants, Maddaloni said the RACs were not as prompt in meeting timeframes for transferring case files for second-level appeals. "Processing timeliness for Part A appeals dropped in 2012," she said.

"Contractors told us it was because of the increase in Recovery Audit Contractor appeals. Part A appeals typically require the review of an entire medical record, so they're much more time and resource intensive to process than Part B appeals."

Maddaloni said the audit could not provide detail on the specific claims. "Most of the Recovery Audit Contractor appeals involved short-term inpatient hospital stays. Aside from that, CMS has limited data available," she said. "However, it's implementing the Medicare Appeals System for first-level appeals. This is a database that will have specific information about appeals. It should make it easier for contractors and CMS to track appeals."

"In fact, two of the three recommendations in our report have to do with the Medicare Appeals System," she explained. "We recommended that CMS use it to oversee contractors and to monitor data quality. Our other recommendation was that CMS encourage information-sharing, like best practices, among its contractors."

John Commins is a senior editor with HealthLeaders Media.

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