The Centers for Medicare and Medicaid Services (“CMS”) recently released its budget proposals for fiscal year (“FY”) 2022, requesting funding to facilitate Qualified Independent Contractors’ (“QIC”) operations at both the second and third levels of the Medicare claim appeals process. Congress has yet to determine whether to appropriate funds consistent with the budget requests.
During the second level of appeal—reconsideration—the QIC conducts an independent review of the administrative record and determines whether the Medicare Administrative Contractor improperly rendered an adverse redetermination decision during the first level of appeal. In general, QICs must make a reconsideration decision within 60 calendar days of the date the QIC receives a timely filed request for reconsideration. In order to aid QICs in adjudicating second-level appeals, CMS requested a total budget of $79.6 million for QIC appeals—$9.2 million more than the FY 2021 level. CMS justified the funding request by citing the agency’s anticipated increase in Medicare Part A claim appeals.
During the third level of appeal, providers are afforded an opportunity to present their case before an Administrative Law Judge (“ALJ”). Despite a clear requirement to render decisions within 90 days, there is a significant backlog of Medicare appeals at this level. In March of 2021, the Department of Health and Human Services stated: “At the end of the first quarter of 2021, a total of 131,961 appeals remained pending at [the Office of Medicare Hearings and Appeals]…”
CMS seeks to address this backlog by requesting $6.2 million in additional funding to enable QICs to participate as a party in over 2,000 ALJ appeals. When the QIC elects to be a party to an ALJ hearing, it may file position papers, submit evidence, provide testimony, call witnesses or cross-examine the witnesses of other parties. According to CMS, “party” status allows QICs to better defend claim denials, “reduc[ing] the ALJ reversal rate and lower[ing] Medicare Trust Fund expenditures.” >Lastly, the $6.2 million in funding would also support the Office of Hearings Case and Document Management System.
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