Faster Medicare Claims Appeals in the Works
A year from now, CMS officials hope to have a faster appeals system in place for Medicare beneficiaries. CMS Administrator Mark B. McClellan, MD, PhD, recently announced efforts to overhaul the claims appeals system by awarding contracts to eight Qualified Independent Contractors (QICs) to perform reconsiderations, or second level claims appeals, of denied Medicare fee-for-service claims. “Seniors and people with disabilities deserve a prompt and consistent and responsive process for their claims appeals in Medicare,” said McClellan. “We are working toward completing our overhaul of the Medicare claims appeals system by October 1, 2005, to better serve Medicare beneficiaries, providers, physicians, and other health care providers.”

The QIC reconsiderations will replace the current “fair hearing” process for Medicare Part B claims and establish a new second level of appeal for Medicare Part A claims. Statute requires that reconsiderations must be completed within 60 days from the day the request is filed.

As part of the new process, the eight QICs will be able to bid on specific types of appeals workloads such as Part A, Part B, or durable medical equipment—and in the specific areas of the country for which they will process claims.

CMS will also implement a 60-day decision deadline and improved notices for claims redeterminations, or first-level appeals performed by fiscal intermediaries and carriers. The improved notices will include the specific reasons for the decision and a summary of relevant clinical or scientific evidence used in making the decision. Final regulations to implement the new uniform appeals procedures will be implemented by the end of the year.

A Welcome Suggestion
The home care industry welcomed a recent government report that suggested CMS include a dispensing fee for inhalation therapy drugs. As part of a Government Accountability Office (GAO) report detailing a survey of dispensing fees for inhalation therapy, the suggestion came in the form of a letter from CMS Administrator Mark McClellan, MD, PhD, that said: “After reviewing the comments and the information from the GAO survey and other public sources, we believe that $55 to $64 per month is a reasonable range for a 2005 fee.”

The Medicare Modernization Act mandates that inhalation drugs will be reimbursed next year using an average sales price (ASP) plus 6% formula. In a Notice of Proposed Rule Making released in August, CMS announced reimbursement amounts for two staple inhalation drugs—albuterol sulfate and ipratropium bromide—at rates 89% below current reimbursement levels. However, the agency said it would also consider an “appropriate” dispensing fee for the drugs.

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