ALJ and QIC Vary on appeal policies

GAITHERSBURG, M.D., Nov. 20, 2012—According to Karen Long of DecisionHealth, 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.”

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 here.