OIG Reports on Timeliness of First Level Appeals

On October 13, 2013 the Office of Inspector General (OIG) issued a report on “The First Levels of the Medical Appeals Processes, 2008-2012: Volume, Outcomes, and Timeliness”.  The process focused on redeterminations process for Medicare Parts A and B during 2008-2012.  The surveyed 18 contractors that process redetermination for Medicare Parts A and B and interviewed 5 of them to learn more about how they process redeterminations.

They found in 2012 contractors processed 2.9 million redeterminations, which involved 3.7 million claims, and increase of 33 percent since 2008.  80% of all determination in 2012 involved Part B services, but appeals involving Part A services has risen more rapidly.  In 2012 appeals involving recovery audit contractors accounted for 39 percent of all Part A claims.  Contractors decided in favor of Part A appellants at a lower rate than that for Part B appellants. The contractors largely met the required timeframes for processing redeterminations and paying appeals decided in favor of appellants, but fell short of meeting timeframes for transferring case files for second-levels appeals.

The OIG recommends (1) CMS utilized the Medicare Appeals System (MAS) to monitor contractor performance, (2) continue to foster information sharing among Medicare contractors, and (3) monitor the quality of redetermination data in MAS.

For more information please utilize the following link:

http://oig.hhs.gov/oei/reports/oei-01-12-00150.pdf