Demonstration Overview

On January 1, 2016, the Centers for Medicare & Medicaid Services (CMS) implemented the Qualified Independent Contractor (QIC) Formal Telephone Discussion and Reopening Process Demonstration (referenced here as the Demonstration) with a goal of engaging suppliers and improving the claim submission process for durable medical equipment (DME). As of September 1, 2019, MAXIMUS Federal will begin processing new reconsiderations of DME appeals (the second level of appeal for denied claims) and will continue the existing Demonstration activities for these appeals as appropriate.

The Demonstration initially focused on claims originating in DME Medicare Administrative Contractor (MAC) Jurisdictions C and D. On November 1, 2018, the Demonstration expanded to include most claims originating in MAC Jurisdictions A and B as well. Claims in Jurisdictions A and B for glucose/diabetic testing supplies are not currently eligible for this Demonstration. (Note that claims for glucose/diabetic testing supplies continue to remain eligible for Jurisdictions C and D.) In addition, claims from any jurisdiction that are subject to other CMS initiatives (e.g., authorization for power mobility devices (PMDs), the settlement conference facilitation (SCF) process, etc.) are not eligible for the Demonstration.

The goal of the Demonstration is to educate suppliers about Medicare policies and regulations in order to improve their future billing. The Demonstration has two components:

  1. A telephone discussion, during which appeal experts from MAXIMUS Federal will engage supplier appellants in order to educate suppliers about the related coverage and policy requirements, discuss issues at appeal, and identify information that may result in a favorable resolution. The telephone discussion process is voluntary and will be recorded and included as part of the administrative case file forwarded to the Office of Medicare Hearings and Appeals (OMHA).
  2. Analysis of previously completed unfavorable reconsideration decisions to identify potential appeals that are pending an Administrative Law Judge (ALJ) assignment at OMHA and can now be resolved favorably through the reopenings process.

Participation in the Demonstration process will have the following benefits:

  • Educate suppliers on Medicare coverage policies and the root causes of denials.
  • Dialog between the supplier community and expert reconsideration reviewers to allow for an exchange of information and detailed review of regulations and policies applicable to the appeal.
  • Identification of documentation that may result in favorable decisions at reconsideration.
  • Identification of appeals previously closed with unfavorable reconsideration decisions that can now be reopened and resolved favorably under this Demonstration.

For more information about the Demonstration, please follow the links or contact:

MAXIMUS Federal
Formal Telephone Discussion and Reopening Process Demonstration
3750 Monroe Avenue, Suite 777
Pittsford, NY 14534-1302
Phone: 585-348-3202
Fax: 585-869-3315
Email: MaximusQICDemo@maximus.com

CMS has additional information about the demonstration on its website. Read more about reconsiderations and the Demonstration here.

 

Medicare Durable Medical Equipment (DME) Appeals