A new report by the HHS Office of Inspector General (OIG), published Nov. 15, finds that administrative law judges (ALJs) were inconsistent in interpreting Medicare policies and likely to overturn findings from previous appeals levels.
 
ALJs administer the third level of Medicare appeals, following a redetermination by the payment contractor and a second review by a qualified independent contractor (QIC).
 
Findings by ALJs generally are more likely to be favorable to providers than those at other appeal levels. Indeed, the OIG found that ALJs reversed QIC decisions in 56% of cases in fiscal 2010.
 
However, the OIG also found that ALJ rulings were less likely to be favorable when CMS contractors participated in appeals. The OIG recommended that CMS increase participation by contractors in ALJ appeals. CMS noted that this movement is already in progress, with recovery auditors (RACs) and zone program integrity contractors (ZPICs) increasingly participating in appeals.
 
The OIG also recommended that CMS implement additional joint trainings for ALJs and QICs on Medicare policies, and CMS concurred.