I’ll begin this one-day-late posting of all things audit with a brief addendum to last Friday’s post.
Hotel living still represents the dregs of existence.
Now that we have that out of the way, it has come time to respond to the occasional e-mail interactions that I receive in my inbox. This past Tuesday afternoon, I received one such communique from an undisclosed reader in an undisclosed location. The writer informed me that in two separate cases that are in the appeals process, they have been informed by their Qualified Independent Contractor (QIC) that they will not be able to issue a redetermination decision in the mandated 60-day time frame. The letters that the writer has received offers two options: either you allow the QIC to finish the appeal at level 2 or you can escalate the appeal to the next level, the ever-popular Administrative Law Judge (ALJ). To make matters worse, the RAC management tool being utilized by the writer does not allow for the setting of a current status, which will make these claims harder to track.
I’ll make this short, since the posting is one day late, the present day is growing short and I have an abbreviated temper from the giant Burger King sign that was shining into my hotel room window for three straight nights. The ALJ is any provider’s first realistic chance to present claim appeal information to an unbiased party, particularly as it applies to RAC issues. From what we know, the QICs are basically rubber-stamping MAC appeal determinations, and we know that the MACs are giving RAC appeals only a cursory glance before agreeing with the RAC determinations.
Knowing all of this, I would see very little value in waiting for a QIC to render a decision that evidence suggests will be in favor of the original RAC determination. My advice would be to go to the ALJ with the letter from the QIC stating that they couldn’t finish their task order in hand. The worst the ALJ could do is throw it back to the QIC to complete their review.
I now draw the curtains and hope for a better night’s sleep.