Streamlining independent medical review process for digital transformation

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As a federal agency within the United States Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS) is dedicated to advancing health equity, expanding coverage, and improving health outcomes for the American public. CMS retains multiple Qualified Independent Contractors (QIC)s outside contracted independent review organizations with Medicare contracts to handle coverage appeals called reconsiderations. These reconsiderations are reviews of denials of coverage issued by a Medicare Health Plan.

QICs are staffed with CMS doctors and other health professionals who independently review and assess the medical necessity of and coverage for the items and services Medicare Health Plans provide to their enrollees.

As of 2022, more than 28 million Medicare beneficiaries are enrolled in Medicare Health Plans. This number represents 45% of the entire Medicare population. Maximus has served as the Medicare Part C Qualified Independent Contractor — sometimes referred to as an Independent Review Entity — for CMS since the program’s inception in 1987, providing over two million decisions related to expedited and standard case priorities, ensuring this Medicare population has access to fair and unbiased coverage decisions.

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Services provided

  • Robotic Process Automation
  • Hiring and Training Protocol Solution
  • Case creation, closing, compliance and quality control guidance
  • Independent Medical Reviews
  • Strategic technology and process program streamlining

Success achieved

  • 99% timeliness requirement rating
  • Exceptional CPAR scores granted from CMS
  • 99.9 % quality score with zero accuracy findings from CMS’s auditor
  • Improved process efficiencies

Using advanced technologies to improve process efficiencies

Challenge

The COVID-19 pandemic drastically changed not only the type of cases submitted to the QIC requiring reconsideration, but also a significantly increased the volume of cases. In March of 2021, CMS enacted a series of COVID-19-related CMS Program waivers and QIC clarifications to assist in the mitigation of the public health emergency. These changes resulted in significant impacts to the reconsideration process including:

  • A Medicare Health Plan waiver permitting more appeals to be granted ‘expedited’ status which decreased the QIC appeals process completion time to within 72 hours. The COVID-19 pandemic and the resulting program waivers established by the CMS increased the percentage of expedited appeal volume from 17% to nearly 30% of all reconsiderations.
  • A CMS rule clarification broadened the scope of what issues are appealable to the program. This increased the number of appeals being submitted for reconsideration as well as the percentage of appeals requiring physician review. The CMS rule clarification increased the number of appeals requiring medical review (a very costly element of the reconsideration process) from 20% to 30% of all reconsiderations submitted.

Approach

Leveraging more than three decades of experience rendering fast, independent, accurate determination of benefits from trained health professionals, our team was able to tackle these challenges for CMS in several ways:

  • Developing a significant hiring and training protocol to ensure proper staffing for the incoming volume.
  • Promoting internal staff into adjudication roles and providing employees with opportunities to move upwithin the project.
  • Adding physician resources to assist with the increased medical review volumes.
  • Collaborating with the Maximus Credentialing department to source and bolster additional physician panel resources.
  • Offering subspecialty coverage for the increasing volume of more medically complex case types.

Results

Amid all the challenges of the environment, the Maximus team was able to deliver reconsiderations that exceeded CMS leadership expectations. Maintaining a near perfect rating for IRE timeliness and quality, our industry-leading support in the CMS appeals program area was given exceptional Contractor Performance Assessment Reporting (CPAR) scores for the past two years and a 99.9% quality score with zero accuracy findings from CMS’s independent auditor. By using quality processes and technologies that streamlines the most complex QIC operations programs, Maximus was able to increase efficiency and improve its appeal process quality at scale. As a trusted technology and solutions service partner of CMS, we are proud to support the advancement of the nation’s critical health needs, transform clinical care, and establish a blueprint for the future of public health.