OIG Report on Medicare 1st Level of Appeals

October 28, 2013
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Rick Gawenda
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The Office of the Inspector General has released a report on the first level of the appeals process for Medicare Parts A and B from 2008-2012. Medicare refers to the process for the first level of appeals as redetermination. In 2012, contractors processed 2.9 million redeterminations, which involved 3.7 million claims, an increase of 33 percent since 2008. Although 80 percent of all redeterminations in 2012 involved Part B services, redeterminations involving Part A services have risen more rapidly. In 2012, the Medicare program denied 139,275486 million claims, but providers only appealed 3,664,599 million claims which amounts only to 2.6% of all claims denied and only 0.3 percent of the 1.2 billion claims processed in that year.

In 2012, Medicare contractors decided fully or partially in favor of appellants for less than a quarter (24%) of Part A redeterminations in 2012 and RAC’s only decided fully or partially in favor of appellants for 11% for Part A redeterminations. The percentage of Part B redeterminations decided fully or partially in favor of appellants decreased slightly from 2008 (65%) to 2012 (51%).

To read the full report, click HERE.


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