Law clerk Ariel Seiersen contributed to this article.
Continuing to look for ways to reduce the Medicare administrative law judge (ALJ) appeals backlog, CMS has explored enhancing the role of Qualified Independent Contractors (QICs) to resolve disputed claims earlier in the appeals process. Its main pilot in this area is the Telephone and Reopening Process Demonstration (Demonstration), which affords certain providers the ability to present their case to a representative of the QIC and have a live discussion about the merits of the appeal. While initially limited to durable medical equipment claims, CMS expanded the Demonstration to home health and hospice claims within the Part A East QIC jurisdiction. Following the expansion, C2C Innovative Solutions—the Part A East QIC—began offering telephone discussions and reopenings to hospice and home health providers within Medicare Administrative Contractor (MAC) jurisdictions J6 and J15, covering Alaska, American Samoa, Arizona, California, Colorado, Delaware, District of Columbia, Guam, Hawaii, Idaho, Iowa, Kansas, Maryland, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Jersey, New York, Northern Mariana Islands, North Dakota, Oregon, Pennsylvania, Puerto Rico, South Dakota, US Virgin Islands, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. The Demonstration may provide home health and hospice companies with an effective new tool in the Medicare appeals process to help manage very long delays in the ALJ appeals process.
Under the expansion, home health and hospice providers with appeals at the reconsideration level may be invited by CMS to participate in the Demonstration. Providers selected to participate in the Demonstration will be notified by mail with a scheduled date and time for the telephone discussion between two and six weeks after the QIC’s receipt of the reconsideration request. Participation in the Demonstration is voluntary, but at this juncture providers must be specifically invited to do so; there is no current method for a provider to request a QIC telephone hearing under the Demonstration. Providers who elect to participate must promptly submit their acceptance; hearings are generally held approximately one month after the QIC reaches out to providers.
QIC hearings are semiformal and include a recorded telephone discussion with the QIC before the QIC renders its decision. During the telephone discussion, the QIC representative (usually just a single person) will identify materials, evidence, and documentation that would result in a favorable outcome (i.e., “If the provider had evidence of sustained weight loss, we would approve this claim.”). Through this discussion, the provider can learn about the documents the QIC considers critical to its evaluation of the case. And, if the relevant evidence is in fact already in the record, the provider can direct the QIC representative to that evidence (e.g., “The weight measurements on pages 50, 78, and 110 demonstrate weight loss during the period under review.”).
Providers have the opportunity to offer testimony and additional documents not already in the appeal case file to the QIC during the discussion—and should take it. Providers can also determine what documents are in the QIC’s case file, supplement the case file, and clarify any technical discrepancies that may be helpful in adjudicating the claim. Following the discussion, the QIC will conduct a medical or technical review taking into consideration any additional materials, evidence, or documentation provided during the discussion. Note that the current Demonstration only applies to single appealed claims, so this process is not yet feasible for a multiclaim or extrapolated audit.
The telephone conversation will be incorporated into the appeals case file. Because of the additional timing for the telephone discussion, the QIC has 120 days from the date of receiving the appeal—instead of 60—to process the reconsideration. If the provider appeals the QIC’s decision to the ALJ, the ALJ then has access to the recorded telephone conversation as part of the appeals record.
Providers should include their relevant clinical staff in the telephone discussion and ensure that staff are knowledgeable about the case at issue, including the patient’s history and documentation, before participating in the telephone discussion. For home health and hospice cases in particular, the presence of a certifying physician is very important.
The Demonstration is a positive development for home health and hospice providers in that it should promote a new process that expedites resolution of appealed claims and possibly avoids the lengthy ALJ process (and the two- to three-year holding period before the ALJ hearing). It appears that for providers selected to participate, there is little downside to engaging in this voluntary process since it gives them the opportunity to better understand the QIC’s case and anticipate, at the very least, any weaknesses in a claim if an appeal to the ALJ must ultimately be made.