The U.S. Department of Health and Human Safety (HHS) Office of Inspector General (OIG) has issued a report documenting that redeterminations, the first level in the Medicare appeals process through the Centers for Medicare & Medicaid Services (CMS), increased by 33 percent from 2008 to 2012, even though the number of overall claims processed increased by just 3 percent in the same time period.
In 2012, CMS contractors processed 2.9 million redeterminations for Medicare Parts A and B, which involved 3.7 million claims. Part B redeterminations totaled 2.3 million, or nearly 80 percent. However, Part A redeterminations increased by 136 percent from 2008 to 2012, while Part B requests only increased 20 percent. The rate of redeterminations that ended with contractors deciding partially or fully in favor of the provider declined from 50 percent in 2008 to 24 percent in 2012.
For Recovery Audit Contractors (RAC)-related appeals, the rate of favorable decisions decreased from 83 percent in 2009 to 11 percent in 2012. RAC-related claims accounted for only 3 percent of appealed Part B claims in 2012.
CMS said it expects to begin integrating redeterminations into its Medicare appeals system in late 2013. The OIG report recommends that once the system is implemented, CMS should use its access to the redetermination data to conduct detailed analyses of redetermination trends and monitor the timeliness of processing.
