(June 15, 2012): If you have ever been involved in a Medicare postpayment audit, or even a prepayment audit, you may have heard of the "QIC" – the Qualified Independent Contractor. This contractor for the Centers for Medicare & Medicaid Services (CMS) is responsible for adjudicating reconsideration appeal requests from appellants still unhappy with a re-determination decision. As background, when a Medicare claim is denied (either initially or after a ZPIC or RAC review), there are several levels of administrative appeal available to a health care provider. These include:
1. Redetermination Appeal.
2. Reconsideration Appeal.
3. Administrative Law Judge (ALJ) Appeal.
4. Medicare Appeals Council Review.
5. Federal District Court Review.
I. Recent Findings in QIC Report:
A recent report promulgated by a QIC indicated that the vast majority of appellants in Medicare post-payment appeals decide "throw in the towel" and effectively stop their appeal efforts if they lose at the 2nd level (the reconsideration oe "QIC" level of appeal). As we discuss later, this is often not a good appeals strategy. However, if appellants do choose to go further, they may later be confused by another CMS contractor, known as the "AdQIC" – the Administrative Qualified Independent Contractor. While Q2 Administrators currently serves as both a QIC and as the AdQIC, these two contracts have very different roles and responsibilities.
II. Responsibilities of the QIC:
As previously discussed, QICs serve as the mid-level adjudicator in Medicare post-payment appeals. They accept reconsideration appeal requests filed by appellants, gather relevant documents from the appellants and from the lower-level Medicare Administrative Contractor (MAC) who conducted the redetermination review, and actually adjudicate whether the claims qualify for coverage and payment under Medicare's program rules. Notably, like MACs and ZPICs, they are bound by both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). In addition, QICs may review the propriety of a statistical extrapolation, if one was conducted in the case being reviewed. Once the QIC issues a reconsideration decision, an appellant may appeal to an ALJ, at which time the QIC then forwards (or at least is supposed to) all of its records to the ALJ for use in those proceedings.
III. Responsibilities of the AdQIC:
The AdQIC serves a very different purpose than the QIC. The AdQIC only starts its work after an ALJ has made his or her decision in a case. While an AdQIC is supposed to “effectuate” the decision of an ALJ (which presumably refers to the AdQIC coordinating the decision with CMS, the relevant ZPIC, and the relevant MAC to either pay monies back to the provider which are owed as a result of the ALJ decision, or modify the amount due from the provider because of a decision), the AdQIC has effectively become the government's appellate unit and appears to be reviewing nearly every ALJ decision to determine if there is any error or misapplication of the facts by the ALJ. If there is, the AdQIC may make a referral to the Medicare Appeals Council for the Council to review the case “on its own motion.” This is especially true if some of the issues found favorably for a provider involve the extrapolation or one of the many waiver provisions contained in the Social Security Act. While providers have a chance to rebut the AdQIC’s referral, the Council will often take notice of the AdQIC’s action and choose to review a case. The case may then be reversed, upheld, or remanded back to the ALJ for further proceedings and clarification. This can add considerable time and expense to appeals and take what appears a victory for the provider and completely reverse it. As a result, you should take it seriously when the AdQIC contacts you.
IV. Appeal Strategies for Providers:
Prior to appealing a claim, we believe that a health care provider should first carefully assess the services at issue and determine whether they were medically necessary, properly administered and should, in fact, have been paid. If not, the health care provider should not pursue an appeal. If the health care provider believes that these services should have been paid, the provider should keep in mind that the appeals process is a long, drawn-out process. Moreover, it is essential to remember that the first time a provider will have an opportunity to "tell his side of the story" is at the ALJ level of appeal. Prior to that point, only the administrative file is considered by reviewers at the re-determination and reconsideration levels of appeal. As a result, in most instances, a provider's best chance of success is at the ALJ level, which is the first chance the provider gets to speak with an actual person, instead of merely sending in documentation and written arguments in support of payment. While the QIC may be an “independent” contractor, it has been our experience that they tend to strictly apply the rules and are not readily willing to overturn decisions made by lower reviewers. As a result, while providers may occasionally win some claims at the QIC level, their best opportunity to present their case remains at the ALJ level.
To be clear, providers should not just assume that an ALJ will rule in their favor. The ALJs we have practiced before are extremely knowledgeable and experienced in practically every area of Medicare practice. Providers will likely find that the ALJ hearing their case has already thoroughly read their case-file and is prepared to ask the provider a number of tough questions. Further complicating matters is the fact that in most cases involving over $100,000 a representative of the ZPIC will also be present during the ALJ hearing presenting the reasons why the claims were denied. Despite these challenges, the ALJ level of appeal is a health care provider's best opportunity to identify out any points missed by other reviewers and explain why the services at issue should be paid. As you can imagine, the administrative appeals process has become quite complicated. If your practice is subjected to a significant post-payment audit, we recommend that you contact a qualified health attorney for assistance.
Robert Liles is the managing member of Liles Parker PLLC, a Washington D.C.-based health law and business transactions firm. Robert represents clients in Medicare and Medicaid administrative appeals, fraud and abuse issues, Compliance Plan drafting and implementation, and training of healthcare professionals in legal issues which might affect them. For a complimentary consultation about your case, call today at 1-800-475-1906.