The General Accounting Office (GAO) has released a report criticizing the backlogged Medicare claims appeals system.
The report, Medicare Appeals: Disparity between Requirements and Responsible Agencies’ Capabilities, evaluated whether the current Medicare appeals process is meeting requirements set by the Benefits Improvement and Protection Act (BIPA), such as timely review of appeals. BIPA contained provisions to revamp the Medicare appeals process beginning Oct. 1, 2002, but many required changes have not yet been implemented.
QIOs were not mentioned in the GAO report, which focused on payment appeals, but not on appeals for continuation of stay or termination of services. The QIOs eventually are expected to handle new continuation of stay and termination of services reviews in nursing homes, home health agencies, hospice, and rehabilitation facilities as part of the new appeals system, but CMS has not announced a start date.
QIOs also will be eligible to compete to become Qualified Independent Contractors (QICs), which will conduct expedited reconsiderations of QIO reviews for cases in which care is going to be discontinued. However the RFP to compete for QICs has not yet been released.
The GAO report said that long processing times, backlogs of unresolved cases, and lack of coordination between CMS, the carriers, the Office of Hearings and Appeals, and the Medicare Appeals Council continue to plague the system.
GAO recommended that HHS and the Social Security Administration form an interagency steering committee to guide various aspects of the process that will need to be addressed to meet BIPA’s requirements. For more info, www.gao.gov