LAKE SUCCESS, N.Y., Nov. 8 /PRNewswire/ -- IPRO has been chosen by the Centers for Medicare & Medicaid Services (CMS) to perform reconsiderations, or second level claims appeals, of denied Medicare fee-for-service claims. Designated as a Qualified Independent Contractor (QIC), IPRO is one of only eight organizations across the U.S. now eligible to bid on this work.
The initiative, recently announced by CMS Administrator Mark B. McClellan, M.D., Ph.D., is a key step in helping Medicare beneficiaries resolve their appeals more quickly and efficiently, as part of a comprehensive overhaul of the Medicare claims appeals system. IPRO is an independent health care quality evaluation and improvement organization.
The reconsiderations that will be conducted by IPRO and the other new QICs will replace the current “fair hearing” process for Medicare Part B claims and establish a new second level of appeal for Medicare Part A claims. Statute requires that reconsiderations must be completed within 60 days from the day the request is filed.
As part of the new QIC process, IPRO and the other contractors will be able to bid on specific types of appeals workloads such as Part A, Part B or durable medical equipment, and in the specific areas of the country for which they will process claims.
“We are thrilled to be one of only eight organizations chosen to take part in this new process to assist Medicare beneficiaries,” says Theodore O. Will, Chief Executive Officer, IPRO. “By selecting IPRO, CMS has confirmed its faith in our ability to make impartial judgments on benefits appeals, as demonstrated by our longtime work in health plan external appeals and many other areas.”
One of the first organizations to provide independent external reviews of health plan benefit denials, IPRO has performed tens of thousands of reviews for medical necessity and appropriateness and has extensive experience handling appeals of denial of care and payment. IPRO makes objective determinations on appeals covering the full range of disputes among enrollees, providers and health plans such as eligibility, contract interpretation, medical necessity and experimental/investigational treatment. IPRO is certified to conduct independent external appeals in fifteen states and the District of Columbia. In addition, IPRO reviews appeals on a national scope for ERISA plans. IPRO has developed and trained a multi- state panel of more than 300 board certified specialists who represent almost all medical specialties and sub-specialties and can provide a full range of clinical reviews.
IPRO also conducts independent reviews of Medicare+Choice (Medicare Advantage) coverage terminations. All Medicare Advantage enrollees have the right to request a Quality Improvement Organization fast-track review to appeal a decision to terminate coverage of services. Termination occurs when the Medicare Advantage organization decides to discontinue coverage of services currently being provided to an enrollee. To learn more about IPRO’s involvement in Fast Track Appeals Rights for Medicare+Choice Enrollees, visit http://providers.ipro.org/.
The Social Security Act (SSA), Sections 1869 and 1879, entitles Medicare beneficiaries and providers the right to appeal adverse determinations of Medicare Part A and B claims. Currently, several entities, such as Medicare carriers and fiscal intermediaries, are involved in the Medicare administrative appeal process.
The Benefits Improvement and Protection Act of 2000, modified by the Medicare Modernization Act of 2003, created the QIC designation and substantially changed the Medicare appeals process by revising time limits for filing appeals, reducing the timeframe for decision-making, and establishing the right to an expedited reconsideration determination.
With 20 years experience in health care quality evaluation, IPRO holds major contracts with state and federal governments to review the cost and quality of services provided to Medicaid recipients, Medicare beneficiaries, and patients enrolled in managed care organizations. Based in Lake Success, New York, IPRO also holds contracts with private-sector clients to improve the quality of privately financed services. For more information, please visit http://www.ipro.org/ or call Harry M. Feder, Senior Vice President, IPRO, (516) 326-7767 ext. 528.
IPRO
CONTACT: Dennis Tartaglia, or Whitney Wasserman, or Lauren Sabados,+1-212-481-7000, or Spencer Vibbert, +1-516-326-7767, ext. 652, all for IPRO