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OIG 2011 Work Plan: The Medicare Audits and the Appeals Process

With respect to the Medicare appeals process, the OIG plans to review and examine the following:

• The timeliness of the Medicare contractors’ determinations on requests for reconsideration at the first level of Medicare appeals as they have 60 days to conclude a redetermination pertaining to a denied claim.
• The characteristics of cases brought before an administrative law judge (ALJ) and whether a CMS representative participates in the ALJ hearings.
• Appropriateness and consistency of the national provider identifier (NPI) enumeration data and the Medicare Provider Enrollment, Chain and Ownership System (PECOS).
• Quality Assurance Surveillance Plan (QASP) performance evaluation reports of Medicare Administrative Contractors (MACs) “to determine whether the reports address the results of activities performed by the MACs.” QASP was developed to monitor and evaluate the MACs. The OIG will examine whether CMS addresses the deficiencies identified in the QASP reports.
• Whether Zone Program Integrity Contractors (ZPICs) identified and addressed potential fraud and abuse incidents and whether there were any issues or barriers in performing their contractual responsibilities. The ZPICs were established to replace the program safeguard contractors (PSCs) in an effort to consolidate all program integrity functions into a single contractor.
• How ZPICs addressed instances of conflicts of interest, whether conflicts were disclosed, and how they were resolved.
• How CMS addresses contractor vulnerabilities identified by ZPICs, PSCs, and Medicare Drug Integrity Contractors (MEDIC).
• Because of discovered problems with Recovery Audit Contractor (RAC) reporting of potential fraud and because the Affordable Care Act expanded the RAC program to Medicaid and Medicare Parts C and D, the OIG will review the RAC program and CMS’s oversight of the program.

For more information, please contact Abby Pendleton, Esq. and Jessica L. Gustafson, Esq. at (248) 996-8510 or (212) 734-0128 or visit the the RAC specialty page on the HLP website.

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