CMS to develop national Medicare Appeals System

The Centers for Medicare and Medicaid Services is developing a national Medicare Appeals System, MAS, which will eventually support the end-to-end administrative appeals process and provide oversight of appeals and of the Medicare program in general.

Peter Askanez, spokesman for CMS, said the appeals system is being driven by a provision in the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000, which requires qualified independent contractors to maintain second-level Medicare appeals data in an electronic database.

Section 521 of the Act requires that the data be able to help identify specific claims that give rise to appeals – situations suggesting the need for increased provider education and situations suggesting the need for changes in national or local coverage policy.

Multiple workload management systems and databases are being used to handle current appeals. However, the data systems are incompatible and don't let users identify problems and create solutions in the appeals process.

"The MAS will be the first system to track Medicare appeals across different levels on a national basis," said Askanez.

Currently, 90 percent of Medicare Part B "fair hearings" must be completed in 120 days and QIC, or Quality Improvement Committee, reconsiderations must be completed within 60 days from the day the request is filed.

Askanez said the organization and administrative QICs would execute an extensive amount of testing to address any issues and reduce implementation risks. CMS anticipates significant savings from the deployment of an electronic appeals case file and will use data gathered from the MAS and QIC cost reports to calculate savings.

American Management Systems won the MAS development contract in September 2003, and the MAS will comprise commercial off-the-shelf software packages, including Siebel eHealthcare 7.7, Cognos and Oracle.

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