OIG Releases Medicare Appeals Process Information

The US Health and Human Services, Office of Inspector General (OIG) has released a report, The First Level of the Medicare Appeals Process, 2008-2012: Volume, Outcomes, and Timeliness, focusing on the redetermination phase of the Medicare appeals process for Part A and B claims.  According to the study, Medicare Administrative Contractors (MACs) processed 2.9 million redeterminations, which involved 3.7 million claims, showing 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.  In fact, the OIG report says that between 2008 and 2012, the redeterminations handled by MACs have seen a 148 percent increase in Medicare Part A claims.  The majority of this increase comes from appeals from Medicare recovery audit contractors (RACs).  As the number of Part A appeals exploded, those providers appealing these claims have seen their chances at a favorable decision at the redetermination level go down.

In 2008, providers appealing a Part A decision had a 50 percent chance of the MAC deciding in their favor at the redetermination level, but in 2012 those chances fell to 24 percent.  Providers appealing Part B claims had a 65 percent chance of a favorable decision at the redetermination level in 2008 and a 51 percent in 2012.  MACs largely met the 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 reconsideration, the second level of Medicare appeals.  The Centers for Medicare & Medicaid Services (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, according to the OIG report.  To obtain a copy of the full report, click here.