The Qualified Independent Contractor (QIC) Telephone Discussion and Reopening Process Demonstration ends December 31, 2021. Despite clear benefits to Medicare and suppliers, CMS has no plans to extend the demonstration or make it permanent. DME stakeholders should not let it fade away quietly.
Going Backwards
Suppliers cannot contact reviewers during audits or redeterminations, the first level of appeal. By terminating the telephone demonstration, CMS is effectively returning to a process that provides for no dialogue until the administrative law judge (ALJ). The ALJ cannot resolve every dispute allowed to fester simply because there is no substantive communication earlier in the process. As we have seen, an overwhelmed ALJ is bad for Medicare.
Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 limits Medicare overpayment recovery through the second level of appeals. Affirmation decisions by the QIC, however, activate offset triggers to recoup disputed amounts. These overpayments, especially when extrapolated, can result in staggering and sustained offsets that risk putting suppliers out of business before they can engage with an ALJ to make their case.
That might make sense if the QIC discussion reversal rate was low, but that has not been the case. In fact, 61 percent of cases during the first five years of the demonstration resulted in fully favorable appeals. The favorable rating reached a staggering 70 percent in 2020.
Going Backwards
Suppliers cannot contact reviewers during audits or redeterminations, the first level of appeal. By terminating the telephone demonstration, CMS is effectively returning to a process that provides for no dialogue until the administrative law judge (ALJ). The ALJ cannot resolve every dispute allowed to fester simply because there is no substantive communication earlier in the process. As we have seen, an overwhelmed ALJ is bad for Medicare.
Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 limits Medicare overpayment recovery through the second level of appeals. Affirmation decisions by the QIC, however, activate offset triggers to recoup disputed amounts. These overpayments, especially when extrapolated, can result in staggering and sustained offsets that risk putting suppliers out of business before they can engage with an ALJ to make their case.
That might make sense if the QIC discussion reversal rate was low, but that has not been the case. In fact, 61 percent of cases during the first five years of the demonstration resulted in fully favorable appeals. The favorable rating reached a staggering 70 percent in 2020.
Without verbal interaction, many of those vindicated suppliers would have likely been forced to repay disputed overpayments before winning them back – several years later – at the ALJ. Never mind the costs associated with unnecessary appeal proceedings.
Education Flows Both Ways
With the demonstration, CMS sought to “educate suppliers on Medicare coverage policies and the root causes of denials.” Reviewers certainly helped suppliers correct process errors sooner in the process, avoiding untold future denials. On the other hand, a majority of telephone discussions completed through 2020 resulted in fully favorable appeals.
It seems, then, education goes both ways.
Suppliers frequently educate reviewers on nuances of the documentation collected. In both cases, the result is more accurate determinations sooner in the appeals process than either party could expect without verbal discussion and exchange. By avoiding unnecessarily protracted appeal steps, the demonstration saves money for Medicare and suppliers.
SOURCE LINKS
https://www.cms.gov/medicare/appeals-and-grievances/orgmedffsappeals
https://med.noridianmedicare.com/web/jddme/article-detail/-/view/2230715/qic-telephone-discussion-and-reopening-process-demonstration-ending
https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Downloads/Medicare-Appeals-Demonstration-2019-Fact-Sheet.pdf
https://www.medicaredmeappeals.com/demonstration-overview
https://www.miravistallc.com/blog/the-qic-is-callingliterally
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