ALJ, QIC Vary on Policy Interpretations Leading to Reversals on Appeal

By
Original story posted on: November 15, 2012

alert-powered-by-decision-health

A new Office of Inspector General (OIG) report noting 56 percent of appeals are reversed at the administrative law judge (ALJ) level recommends clarifying unclear Medicare policies that are interpreted differently at the levels of appeal.

ALJs decide cases at the third level of appeal after qualified independent contractors (QICs). The November report found that ALJs have less strict interpretations of Medicare policies than QICs. “Most ALJ staff noted that ALJs often decided in favor of appellants when the intent, but not the letter, of a Medicare policy was met,” the report stated.

But QICs “try to follow Medicare policy strictly,” the report stated.

ALJs decided 40,682 appeals in fiscal year 2010, 85 percent of which were filed by providers. The report shows 96 providers (2 percent) accounted for almost one-third of all ALJ appeals in fiscal year 2010.

The report also showed success rates varied by type of provider. For example, for Part A, 72 percent of hospital appellants received fully favorable ALJ decisions compared with 62 percent for home health agencies and hospices and 51 percent for skilled nursing facilities. For Part B, diagnostic testing providers received fully favorable ALJ decisions 63 percent of the time compared with 60 percent for practitioners.

Read the report at https://oig.hhs.gov/oei/reports/oei-02-10-00340.pdf.

RAC News

Recovery auditor (RAC) Connolly posted three issues for carriers, outpatient hospitals and physicians. HealthDataInsights, the Region D RAC, posted one issue for suppliers.

Note: HealthDataInsights’ issue states that it was approved on a date in the future, Dec. 2.

Carrier

Name of issue

Date approved

Regions/states where it is active

Description of issue

Document sources

Reclast (zoledronic acid) administered more frequently than once annually

10/31/12

All TrailBlazer states

Reclast (zoledronic acid) should be administered no more frequently than once annually. HCPCS code J3488 represents 1 mg per unit and should be billed one unit for every 1 mg per patient and no more frequently than once annually.

CMS Pub. 100-02 chapter 15; Reclast package insert Novartis

Outpatient hospital

Name of issue

Date approved

Regions/states where it is active

Description of issue

Document sources

Hyperbaric oxygen therapy – excessive units

11/14/12

RAC Region C

The purpose of this semi-automated review procedure is to identify claims that reported excessive units for hyperbaric oxygen therapy, HCPCS code C1300.

Federal Register Vol. 76, No. 137, page 23; MLN Matters MM3632

Physician

Name of issue

Date approved

Regions/states where it is active

Description of issue

Document sources

Incorrect billing of modifier in units field

11/14/12

RAC Region C

Overpayment exists where provider erroneously billed procedural modifier in the units field.

CMS Transmittal 1104

Suppliers

Name of issue

Date approved

Regions/states where it is active

Description of issue

Document sources

Immune Globulin injection (Vivaglobin), 100 mg  - dose vs. units billed

12/2/12

RAC Region D

Immune Globulin injection (Vivaglobin), 100 mg (J1562) should be billed one unit for every 100 mg administered per patient.

Noridian LCD L11570; CMS Pub. 100-02 chapter 15; MLN Matters MM5718; Vivaglobin package insert, CSL Behring Gmbh manufacturer website

About the Author

Karen Long is the editor of Physician Solutions for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

To comment on this article please go to editor@racmonitor.com

Karen Long

This email address is being protected from spambots. You need JavaScript enabled to view it.