Andrea Stark makes case for making demo permanent

YARMOUTH, Maine – The contract may be running out for a demonstration that allows HME providers to try to resolve denied claims by phone, but Andrea Stark says, “We’re onto something here,” and hopes CMS will make it a permanent part of the statement of work for the QIC. 

The QIC, which is run by Maximus, recently announced it is winding down the demo per a contract that ends Dec. 31, 2021. 

“Clearly, DME is complicated and suppliers feel better when they can talk to someone and supplement their cases with additional information,” said Andrea Stark, a Medicare consultant and reimbursement specialist for MiraVista. “It also leads to much more favorable results.” 

The demo was originally pitched and launched by C2C Innovative Solutions in 2016. It was taken over by Maximus in 2018. 

During a recent Jurisdiction C Council meeting, Stark says a QIC representative shared that there’s a 67% favorable rate of resolution with phone discussions compared to 30% with written reconsiderations. 

“That’s more than doubly favorable,” she said. “That, in and of itself, is worth continuing it in some form.” 

Since the demo was a tactic to reduce the backlog at the ALJ and since that backlog has been reduced 69% as of March of this year, CMS might think it’s no longer necessary, but that’s short-sighted, Stark says. 

“We shouldn’t have to wait to get to the third level of appeals to incorporate a more efficient way of resolving denials,” she said. “You have to look at this from an efficiency standpoint and an outcomes standpoint.” 

Another reason to resolve denials sooner in the process: There are financial consequences for providers to “kicking the can down the road” to the ALJ, Stark says. 

“We can’t forget that suppliers fighting post-payment recoveries lose certain rights to defer offsets and recoupments after an unfavorable QIC determination,” she said. “For those that appeal a post pay-recovery under the 935 statute, if the QIC determination is favorable, suppliers can keep that money in their pocket. However, if the decision is unfavorable, the supplier has to pay back the recoupment with interest, while they wait for their day in court at the ALJ. Any means to deliver favorable responses earlier in the process benefits all parties, including CMS and higher appeals dockets.”