OIG Issues Report on Medicare Part A and B Redeterminations for 2008-2012.

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a report examining redeterminations processed from 2008 to 2012.  Redeterminations are the first level of the appeals process for Medicare Parts A and B. 

The OIG found that from 2008 to 2012, redeterminations processed by contractors increased by 33 percent.  In 2012, contractors processed 2.9 million redeterminations involving 3.7 million claims.  Contractors decided in favor of Part B appellants more often than for Part A appellants, and 80 percent of all 2012 redeterminations involved Part B services.  However, the OIG found that redeterminations involving Part A services have risen more rapidly than those of Part B services. The OIG also found that timeframes for processing redeterminations and paying appeals decided in favor of appellants were mostly met by contractors, but that timeframes for transferring case files for second-level appeals were largely not met.  CMS improves processing of redeterminations by contractors through methods such as fostering communication among contractors and implementing the Medicare Appeals System (MAS) for first-level appeals.

The OIG recommended that CMS:

1. Use the MAS to monitor contractor performance;
2. Continue to foster information sharing among Medicare contractors; and
3. Monitor the quality of redeterminations data in MAS.

CMS concurred with all three recommendations.

The OIG report on Medicare Part A and Part B redeterminations is available at:

https://oig.hhs.gov/oei/reports/oei-01-12-00150.pdf.

Department of Health and Human Services Office of Inspector General.  “The First Level of the Medicare Appeals Process, 2008-2012: Volume, Outcomes and Timeliness.”  OEI-01-12-00150.  3 Oct. 2013

About the Author

Ms. Shuman assists health care organizations to develop, implement and evaluate their compliance programs and HIPAA privacy programs. Ms. Shuman specializes in our firm’s HIPAA Privacy services, including leading privacy investigations, breach risk assessments, breach notification letters, breach reporting to the Office for Civil Rights and corrective actions plans. She specializes in serving as Interim Privacy Officer for large health care systems, managed care organizations, comprehensive cancer center and health care business associate.