New OIG report: Is it good or bad?

WASHINGTON - Industry stakeholders worry how a new report from the Office of Inspector General (OIG) that found administrative law judges (ALJs) reversed 56% of the decisions made by qualified independent contractors (QICs) will be interpreted.

While stakeholders are more apt to believe the ALJs, which administer the third level of appeal, are spot on and the QICs, which administer the second level of appeals, are dead wrong, that may not be what the OIG, or CMS for that matter, believes.

"They are saying that a lot of claims get overturned so that must mean that the ALJs are not properly following the Medicare guidelines," said Edward Vishnevetsky, an associate at Munsch Hardt Kopf & Harr.

The OIG initiated the report to assess the impact of rule changes in 2005 that sought to increase the neutrality and effectiveness of the ALJs.

In its report, the OIG issued 10 recommendations, two of which stakeholders find especially troubling. First, the agency would like to see an increase in CMS's participation in the process. It found that when this was the case, the denial was less likely to be overturned. Second, the agency would like to create a filing fee for providers who wish to appeal.

"The OIG wants to reduce the overturn rate and they are going to make it harder for providers to do so by charging a fee," said Walt Gorski, vice president of government affairs for AAHomecare. "All providers should have fair hearings to show that what they provided was medically necessary."

A few of the OIG's recommendations to CMS could benefit providers, say stakeholders. Those include providing coordinated training on Medicare policies for ALJs and QICs, and clarifying unclear Medicare policy.

"These are definitely right on," said Jill Longo, an attorney consultant with the Audit Team and a former attorney adviser in the Cleveland ALJ office. "Each individual ALJ interprets it differently, and they interpret it differently than the Medicare contractors. They need to make sure all the regulations and all the education happen across the whole system from Medicare contractors through the auditors to the ALJs."

To read the OIG's report: https://oig.hhs.gov/oei/reports/oei-02-10-00340.pdf