TABLE 1 09:35 Tuesday, March 5, 2002 1
Annual Report of Medicare Reconsideration Results:
National Summary of Final Decisions and Value of Contested Claims
for Cases Decided During 2001, by Service
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $ $ Ret $
Appealed Service 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld Disenr W/drawn
Practitioner Services 6073 4332 71.33 824 13.57 76 1.25 85 1.40 756 12.45 $9,772,732 $1,387,139 $7,032,248 $136,783 $1,216,563
OPD Mental Health 131 87 66.41 20 15.27 5 3.82 1 0.76 18 13.74 $199,132 $34,202 $136,048 $1,520 $27,362
Hospice Care 9 4 44.44 1 11.11 1 11.11 0 0.00 3 33.33 $17,865 $2,978 $8,933 $0 $5,955
Non-Medicare Benefit 4410 3668 83.17 207 4.69 21 0.48 9 0.20 505 11.45 $3,925,561 $193,608 $3,274,417 $8,011 $449,526
Emergency Room 737 460 62.42 201 27.27 12 1.63 0 0.00 64 8.68 $704,344 $197,828 $445,352 $0 $61,164
Inpatient Hospital 1034 462 44.68 240 23.21 26 2.51 14 1.35 292 28.24 $13,789,807 $3,374,102 $6,334,776 $186,709 $3,894,220
Clinic (Lab, X-ray) 1058 694 65.60 174 16.45 5 0.47 15 1.42 170 16.07 $1,027,910 $171,480 $676,692 $14,573 $165,165
Nursing Home Care 3046 1610 52.86 848 27.84 314 10.31 5 0.16 269 8.83 $17,301,189 $5,708,370 $10,036,507 $28,400 $1,527,912
Therapies 586 396 67.58 124 21.16 13 2.22 5 0.85 48 8.19 $1,649,145 $367,258 $1,132,732 $14,071 $135,084
Ambulance 595 378 63.53 99 16.64 8 1.34 0 0.00 110 18.49 $622,073 $107,687 $399,381 $0 $115,005
Home Health Care 240 130 54.17 50 20.83 9 3.75 2 0.83 49 20.42 $1,081,601 $245,614 $606,147 $9,013 $220,827
DME/Medical Supplies 3380 2768 81.89 345 10.21 29 0.86 2 0.06 236 6.98 $2,817,602 $299,683 $2,319,520 $1,667 $196,732
TOTAL All Services 21299 14989 70.37 3133 14.71 519 2.44 138 0.65 2520 11.83 $52,908,960 $12,089,947 $32,402,750 $400,748 $8,015,514
Dollar figures are estimates based on historic data from Reconsideration Appeals. Mean values from a 5 year
period are applied when missing values occur. Partial overturn decisions have the dollar value apportioned to
the appropriate category, equally divided between $ Upheld and $ Overturned.
Center for Health Dispute Resolution
TABLE 2 09:35 Tuesday, March 5, 2002 2
Annual Report of Medicare Reconsideration Results:
National Summary of Final Decisions and Value of Contested Claims
for Cases Decided During 2001, by Region
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $ $ Ret $
Region 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld Disenr W/drawn
01: Boston 929 685 73.74 111 11.95 63 6.78 4 0.43 66 7.10 $2,938,433 $567,855 $2,155,983 $17,445 $197,150
02: New York 1966 1347 68.51 353 17.96 92 4.68 17 0.86 157 7.99 $6,228,703 $1,808,400 $3,813,783 $42,995 $563,525
03: Philadelphia 1811 1359 75.04 228 12.59 40 2.21 11 0.61 173 9.55 $4,887,910 $892,202 $3,253,535 $19,474 $722,699
04: Atlanta 2723 1839 67.54 464 17.04 76 2.79 52 1.91 292 10.72 $7,835,049 $2,265,146 $4,296,619 $142,389 $1,130,896
05: Chicago 1081 724 66.97 199 18.41 46 4.26 12 1.11 100 9.25 $3,134,854 $955,441 $1,758,825 $33,114 $387,474
06: Dallas 1854 863 46.55 321 17.31 18 0.97 20 1.08 632 34.09 $5,251,578 $1,085,533 $1,574,466 $66,453 $2,525,126
07: Kansas City 494 350 70.85 93 18.83 8 1.62 3 0.61 40 8.10 $1,155,632 $252,385 $704,843 $16,555 $181,850
08: Denver 518 340 65.64 66 12.74 5 0.97 3 0.58 104 20.08 $921,911 $168,416 $617,811 $2,752 $132,933
09: San Francisco 8931 6788 76.00 1140 12.76 132 1.48 14 0.16 857 9.60 $18,224,088 $3,447,125 $12,787,734 $56,354 $1,932,876
10: Seattle 992 694 69.96 158 15.93 39 3.93 2 0.20 99 9.98 $2,330,800 $647,446 $1,439,152 $3,218 $240,984
TOTAL All Regions 21299 14989 70.37 3133 14.71 519 2.44 138 0.65 2520 11.83 $52,908,960 $12,089,947 $32,402,750 $400,748 $8,015,514
Dollar figures are estimates based on historic data from Reconsideration Appeals. Mean values from a 5 year
period are applied when missing values occur. Partial overturn decisions have the dollar value apportioned to
the appropriate category, equally divided between $ Upheld and $ Overturned.
Center for Health Dispute Resolution
TABLE 3 09:35 Tuesday, March 5, 2002 3
Annual Report of Medicare Reconsideration Results:
National Summary of Final Decisions and Value of Contested Claims
for Cases Decided During 2001, by Region and Service
------region=01: Boston ------
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $
Appealed Service 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld
TOTAL All Services 929 685 73.74 111 11.95 63 6.78 4 0.43 66 7.10 $2,938,433 $567,855 $2,155,983
Practitioner Services 250 197 78.80 25 10.00 7 2.80 2 0.80 19 7.60 $402,302 $45,862 $322,647
OPD Mental Health 9 4 44.44 1 11.11 1 11.11 0 0.00 3 33.33 $13,681 $2,280 $6,840
Non-Medicare Benefit 126 106 84.13 3 2.38 0 0.00 1 0.79 16 12.70 $112,159 $2,670 $94,356
Emergency Room 14 8 57.14 4 28.57 2 14.29 0 0.00 0 0.00 $13,380 $4,778 $8,601
Inpatient Hospital 23 16 69.57 1 4.35 0 0.00 1 4.35 5 21.74 $306,737 $13,336 $213,382
Clinic (Lab, X-ray) 34 27 79.41 4 11.76 0 0.00 0 0.00 3 8.82 $33,033 $3,886 $26,232
Nursing Home Care 325 206 63.38 56 17.23 52 16.00 0 0.00 11 3.38 $1,845,990 $465,758 $1,317,753
Therapies 17 16 94.12 1 5.88 0 0.00 0 0.00 0 0.00 $47,842 $2,814 $45,028
Ambulance 30 18 60.00 8 26.67 0 0.00 0 0.00 4 13.33 $31,365 $8,364 $18,819
Home Health Care 13 8 61.54 3 23.08 0 0.00 0 0.00 2 15.38 $58,587 $13,520 $36,053
DME/Medical Supplies 88 79 89.77 5 5.68 1 1.14 0 0.00 3 3.41 $73,358 $4,585 $66,272
------region=02: New York ------
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $
Appealed Service 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld
TOTAL All Services 1966 1347 68.51 353 17.96 92 4.68 17 0.86 157 7.99 $6,228,703 $1,808,400 $3,813,783
Practitioner Services 650 502 77.23 77 11.85 8 1.23 11 1.69 52 8.00 $1,045,986 $130,346 $814,260
OPD Mental Health 18 13 72.22 2 11.11 1 5.56 1 5.56 1 5.56 $27,362 $3,800 $20,521
Hospice Care 1 1 100.00 0 0.00 0 0.00 0 0.00 0 0.00 $1,985 $0 $1,985
Non-Medicare Benefit 192 160 83.33 16 8.33 4 2.08 0 0.00 12 6.25 $170,909 $16,023 $144,204
Emergency Room 18 15 83.33 2 11.11 0 0.00 0 0.00 1 5.56 $17,202 $1,911 $14,335
Inpatient Hospital 139 86 61.87 33 23.74 7 5.04 1 0.72 12 8.63 $1,853,755 $486,778 $1,193,605
Clinic (Lab, X-ray) 114 88 77.19 13 11.40 0 0.00 2 1.75 11 9.65 $110,758 $12,630 $85,497
Nursing Home Care 425 169 39.76 145 34.12 65 15.29 1 0.24 45 10.59 $2,413,987 $1,008,195 $1,144,514
Therapies 75 47 62.67 24 32.00 2 2.67 1 1.33 1 1.33 $211,068 $70,356 $135,084
Ambulance 43 31 72.09 8 18.60 0 0.00 0 0.00 4 9.30 $44,957 $8,364 $32,411
Home Health Care 24 7 29.17 10 41.67 2 8.33 0 0.00 5 20.83 $108,160 $49,573 $36,053
DME/Medical Supplies 267 228 85.39 23 8.61 3 1.12 0 0.00 13 4.87 $222,574 $20,423 $191,313
------region=03: Philadelphia ------
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $
Appealed Service 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld
TOTAL All Services 1811 1359 75.04 228 12.59 40 2.21 11 0.61 173 9.55 $4,887,910 $892,202 $3,253,535
Practitioner Services 388 292 75.26 44 11.34 3 0.77 8 2.06 41 10.57 $624,373 $73,219 $472,303
Dollar figures are estimates based on historic data from Reconsideration Appeals. Mean values from a 5 year
period are applied when missing values occur. Partial overturn decisions have the dollar value apportioned to
the appropriate category, equally divided between $ Upheld and $ Overturned.
TABLE 3 09:35 Tuesday, March 5, 2002 4
Annual Report of Medicare Reconsideration Results:
National Summary of Final Decisions and Value of Contested Claims
for Cases Decided During 2001, by Region and Service
------region=03: Philadelphia ------
(continued)
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $
Appealed Service 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld
OPD Mental Health 12 6 50.00 2 16.67 0 0.00 0 0.00 4 33.33 $18,241 $3,040 $9,121
Hospice Care 1 0 0.00 1 100.00 0 0.00 0 0.00 0 0.00 $1,985 $1,985 $0
Non-Medicare Benefit 382 324 84.82 25 6.54 2 0.52 0 0.00 31 8.12 $340,037 $23,144 $289,299
Emergency Room 68 60 88.24 3 4.41 0 0.00 0 0.00 5 7.35 $64,987 $2,867 $57,341
Inpatient Hospital 108 64 59.26 13 12.04 2 1.85 0 0.00 29 26.85 $1,440,328 $186,709 $866,864
Clinic (Lab, X-ray) 59 41 69.49 9 15.25 0 0.00 1 1.69 8 13.56 $57,322 $8,744 $39,834
Nursing Home Care 304 166 54.61 76 25.00 27 8.88 0 0.00 35 11.51 $1,726,711 $508,357 $1,019,555
Therapies 87 67 77.01 16 18.39 0 0.00 2 2.30 2 2.30 $244,839 $45,028 $188,554
Ambulance 39 33 84.62 1 2.56 2 5.13 0 0.00 3 7.69 $40,775 $2,091 $35,547
Home Health Care 7 5 71.43 1 14.29 0 0.00 0 0.00 1 14.29 $31,547 $4,507 $22,533
DME/Medical Supplies 356 301 84.55 37 10.39 4 1.12 0 0.00 14 3.93 $296,765 $32,511 $252,584
------region=04: Atlanta ------
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $
Appealed Service 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld
TOTAL All Services 2723 1839 67.54 464 17.04 76 2.79 52 1.91 292 10.72 $7,835,049 $2,265,146 $4,296,619
Practitioner Services 807 552 68.40 119 14.75 10 1.24 35 4.34 91 11.28 $1,298,632 $199,542 $896,330
OPD Mental Health 14 7 50.00 4 28.57 1 7.14 0 0.00 2 14.29 $21,281 $6,840 $11,401
Non-Medicare Benefit 586 504 86.01 32 5.46 1 0.17 1 0.17 48 8.19 $521,628 $28,930 $449,081
Emergency Room 54 37 68.52 9 16.67 2 3.70 0 0.00 6 11.11 $51,607 $9,557 $36,316
Inpatient Hospital 228 99 43.42 74 32.46 5 2.19 4 1.75 46 20.18 $3,040,692 $1,020,232 $1,353,642
Clinic (Lab, X-ray) 159 106 66.67 27 16.98 1 0.63 6 3.77 19 11.95 $154,478 $26,718 $103,471
Nursing Home Care 357 145 40.62 123 34.45 46 12.89 2 0.56 41 11.48 $2,027,749 $829,276 $954,235
Therapies 88 50 56.82 22 25.00 2 2.27 2 2.27 12 13.64 $247,653 $64,728 $143,526
Ambulance 30 18 60.00 7 23.33 1 3.33 0 0.00 4 13.33 $31,365 $7,841 $19,342
Home Health Care 29 14 48.28 6 20.69 4 13.79 2 6.90 3 10.34 $130,693 $36,053 $72,107
DME/Medical Supplies 371 307 82.75 41 11.05 3 0.81 0 0.00 20 5.39 $309,269 $35,428 $257,169
------region=05: Chicago ------
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $
Appealed Service 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld
TOTAL All Services 1081 724 66.97 199 18.41 46 4.26 12 1.11 100 9.25 $3,134,854 $955,441 $1,758,825
Practitioner Services 336 252 75.00 44 13.10 6 1.79 7 2.08 27 8.04 $540,695 $75,633 $410,349
OPD Mental Health 7 5 71.43 1 14.29 1 14.29 0 0.00 0 0.00 $10,641 $2,280 $8,360
Dollar figures are estimates based on historic data from Reconsideration Appeals. Mean values from a 5 year
period are applied when missing values occur. Partial overturn decisions have the dollar value apportioned to
the appropriate category, equally divided between $ Upheld and $ Overturned.
Center for Health Dispute Resolution
TABLE 3 09:35 Tuesday, March 5, 2002 5
Annual Report of Medicare Reconsideration Results:
National Summary of Final Decisions and Value of Contested Claims
for Cases Decided During 2001, by Region and Service
------region=05: Chicago ------
(continued)
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $
Appealed Service 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld
Non-Medicare Benefit 140 116 82.86 6 4.29 0 0.00 1 0.71 17 12.14 $124,621 $5,341 $103,257
Emergency Room 25 19 76.00 5 20.00 0 0.00 0 0.00 1 4.00 $23,892 $4,778 $18,158
Inpatient Hospital 58 26 44.83 16 27.59 1 1.72 1 1.72 14 24.14 $773,509 $220,050 $353,414
Clinic (Lab, X-ray) 69 46 66.67 13 18.84 0 0.00 2 2.90 8 11.59 $67,038 $12,630 $44,692
Nursing Home Care 228 86 37.72 86 37.72 34 14.91 1 0.44 21 9.21 $1,295,033 $585,037 $585,037
Therapies 32 18 56.25 10 31.25 2 6.25 0 0.00 2 6.25 $90,056 $30,957 $53,471
Ambulance 31 25 80.65 5 16.13 0 0.00 0 0.00 1 3.23 $32,411 $5,228 $26,138
Home Health Care 13 12 92.31 0 0.00 1 7.69 0 0.00 0 0.00 $58,587 $2,253 $56,333
DME/Medical Supplies 142 119 83.80 13 9.15 1 0.70 0 0.00 9 6.34 $118,373 $11,254 $99,616
------region=06: Dallas ------
Recons Recons Recons
Decided Recons Recons Partially Retro Recons $
Appealed Service 2001 Upheld % Overturned % Overturned % Disenrolled % Withdrawn % Total $ Overturned $ Upheld
TOTAL All Services 1854 863 46.55 321 17.31 18 0.97 20 1.08 632 34.09 $5,251,578 $1,085,533 $1,574,466
Practitioner Services 600 235 39.17 96 16.00 2 0.33 9 1.50 258 43.00 $965,526 $156,093 $379,774
OPD Mental Health 10 3 30.00 3 30.00 0 0.00 0 0.00 4 40.00 $15,201 $4,560 $4,560
Hospice Care 1 1 100.00 0 0.00 0 0.00 0 0.00 0 0.00 $1,985 $0 $1,985
Non-Medicare Benefit 385 263 68.31 35 9.09 2 0.52 3 0.78 82 21.30 $342,708 $32,045 $235,000