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OIG: Medicare Part A claims appeals surge

October 3, 2013

The number of first-level appeals of Medicare Part A claims, known as redeterminations, increased more than five-fold for inpatient hospital services and seven-fold for home health services between 2008 and 2012, the Department of Health and Human Services’ Office of Inspector General reported today. The proportion of redeterminations fully or partly favorable to appellants declined for both inpatient and outpatient services over the period, with the largest decline among inpatient redeterminations related to Recovery Audit Contractors, OIG said. Favorable RAC-related inpatient redeterminations fell to 11% in 2012 from 83% in 2009, the first year the RAC program was fully implemented, the agency said. At the same time, the number of Part A case files transferred to the second-level of appeal (reconsideration by a qualified independent contractor) more than tripled and the timeliness of the file transfers fell. OIG recommends that the Centers for Medicare & Medicaid Services use the Medicare Appeals System to monitor the timeliness of redetermination processing; develop a strategy to monitor the quality, accuracy and completeness of the data entered into MAS; and continue to foster information sharing among Medicare contractors. In comments in the report, CMS agreed with the recommendations.