Department of Health and Human Services
 
OFFICE OF 

   
INSPECTOR GENERAL 

 
 
 
 
 
 
 
 
E I
ARLY   MPLEMENTATION 

 
R   Q
EVIEW OF  UALIFIED 

 
I C
NDEP  ENDENT  ONTRACTOR 

 
P M
ROCESSING OF  EDICARE 

 
 
A R  
PPEALS  ECONSIDERATIONS 

 
 
 
Daniel R. Levinson 
  
Inspector General 

 
July 2008 
 
OEI-06-06-00500 
 
      
Office of Inspector General

http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components:  
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections  
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving  program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs  and operations and providing all 
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.  
     
  
  E X E C U T I V E   S U M M A R Y   
OBJECTIVE 
 
To determine the extent to which Qualified Independent Contractors 
(QIC) followed timeliness, correspondence, and data entry requirements 
for Medicare Part A and Part B claims reconsiderations received from 
May 2005 to July 2006.    
BACKGROUND 
Section 521 of the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of  2000, P.L. No. 106-554, requires 
that QICs conduct the second level of Medicare appeals, called 
reconsiderations, for Medicare Part A and Part B claims.  The Centers 
for Medicare & Medicaid Services (CMS) contracted with two QICs that 
began processing Part A reconsiderations in May 2005 and with two 
QICs that began processing Part B reconsiderations in January 2006.   
For this study, we determined whether QICs processed reconsiderations 
within 60 days, as required, by analyzing information contained in the 
Medicare Appeals System (the appeals system) for all reconsideration 
cases through July 2006. We determined whether QICs sent 
correspondence to appellants as required and whether QICs entered 
accurate information in the appeals system by reviewing case files for a 
randomly selected sample of reconsiderations.  We also conducted 
structured interviews with CMS, the four QICs, and staff who conduct 
Administrative Law Judge hearings at the third level of Medicare 
appeals. 
FINDINGS 
Part A  Qualified Independent Contractors met the 60-day processing 
timeframe;  however, Part B contractors did not for 58 percent of 
reconsiderations.  One  Part B QIC did not process 74 percent of  
reconsiderations within 60 days, and the other Part B QIC did not 
process 40 percent of reconsiderations within 60 days.   
Qualified Independent Contractors did not meet all correspondence  
requirements but did include the appropriate content in 
reconsideration decision letters.   Twenty-six percent of case files that 
we reviewed did not have documentation substantiating that QICs sent 
letters acknowledging appeal requests.  Twelve percent of case files 
were missing reconsideration letters; however, when present, QICs 
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decision letters included all required content. Forty percent of case files 
did not have documentation substantiating that QICs sent processing 
delay notifications for Part B cases that were decided late. 
Qualified Independent Contractors  entered inaccurate information 
into  the Medicare  Appeals System  for 54 percent of 
reconsiderations. Fifty-four percent of reconsiderations contained at 
least one item of inaccurate information in the appeals system for 
appellant type, reconsideration request date, acknowledgment letter 
date, decision date, and/or decision type. 
Factors contributing to deficiencies in timeliness, correspondence, 
and data  entry include case transfer delays, unexpected case 
volume, and appeals system challenges.   Three of the four QICs  
reported that lags in case file transfers from Affiliated Contractors that 
process claims affected  adjudication timeframes and other operational 
activities. Both Part B QICs explained that unexpected case volume  
affected their ability to process cases on time. Additionally, all QICs 
reported that, during the early months of implementation, the appeals 
system was frequently unavailable or slow, did not have the ability to 
generate required correspondence, did not support resource  
management activities, and did not interface with databases that 
contained claims information, which affected timeliness and  overall 
workflow. 
RECOMMENDATION 
During our review, the Part A QICs had been processing  
reconsiderations for 15 months and the Part B QICs for 7 months.   We 
found that, during this timeframe, QICs had challenges meeting 
timeliness, correspondence, and data entry requirements. CMS made  
several changes to improve the reconsiderations process, including 
facilitating some improvements in the appeals system, restructuring the 
Part B workload into three jurisdictions, and recompeting the contracts 
among all QICs. However, given QICs deficiencies cited in this report 
and the potential impact of these deficiencies on  the overall Medicare 
appeals process, we recommend that CMS: 
Take further action to ensure that QICs meet timeliness, 
correspondence, and data entry requirements. CMS currently 
employs several mechanisms to  monitor QICs, which include weekly 
reviews of the appeals system data and annual site visit reviews. CMS 
may consider several options for augmenting these mechanisms to  
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E X E C U T I V E   S U M M A R Y   
ensure that QICs meet Federal requirements for processing  
reconsiderations.  For example, CMS could add metrics, such as error 
rates, to its annual reviews to further assess the extent to which QICs 
meet correspondence and data entry requirements.  In addition, to  
better ensure that appeals system data are accurate, CMS could 
validate these data during annual reviews.  CMS could also evaluate 
the costs and feasibility of enabling the appeals system to extract 
information from databases that contain claims data, thereby reducing 
the need for  manual data entry.  Lastly, CMS could monitor the length  
of time that it takes Affiliated Contractors to transfer paper case files to 
QICs, to better ensure that QICs have a reasonable number of days to 
adjudicate reconsiderations.         
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE  
CMS concurred with our recommendation to take further action to 
ensure that QICs meet timeliness, correspondence, and data entry  
requirements and outlined efforts it  has planned or has already taken to  
address it.  These efforts include awarding a contract to a private entity 
that will conduct its own performance evaluation to determine QICs 
adherence to Federal requirements; enabling the appeals system to  
interface with databases that contain claims data; and including 
financial incentives in its contracts with the new Medicare 
Administrative Contractors to forward case files to the QICs within  
4 days for 85 percent of cases.     
CMS also noted that, subsequent to  the time period covered  by our 
review, March 2005 July 2006, it had made several changes to the 
second level  of Medicare appeals, which culminated in the award of 
three new Part B QIC contracts.  CMS reported that all three  
Part B QICs completed over 98 percent of reconsiderations on a timely 
basis during OctoberMarch 2008. CMS provided a table that outlines 
timeliness information for all three Part B QICs during this period. 
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  IT NA TBRLOED   UOC FT  I CO ON N  T E N T S   
 
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
  
 
 
I N T RO DUC T IO N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1 
  
 
 
F I N D IN G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10 
  
  Part A QICs met timeliness requirements; Part B QICs                        
did not. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   10 
  
QICs did not meet correspondence requirements  . . . . . . . . . . . . .  11 
  
  QICs entered inaccurate data into the appeals system. . . . . . . . .  12 
  
  Various factors contributed to processing deficiencies  . . . . . . . . .  14 
  
   
R E C O MMEN D A T ION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  16 
  
  Agency Comments and Office of Inspector General Response . . .  16 

 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  19 
  
  A:  Point Estimates and Confidence Intervals. . . . . . . . . . . . . . . .  19 

  B:   Agency Comments.. . .. . .. . ... . .. . .. . ...  . . . . . .  . . .. . ..22
   
 
 
A C K NO WL E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  26 
  
 
     
  
  I N T R O D U C T I O N  
OBJECTIVE 
To determine the extent to which Qualified Independent Contractors 
(QIC) followed timeliness, correspondence, and data entry requirements 
for Medicare Part A and Part B claims reconsiderations received from 
May 2005 to July 2006. 
BACKGROUND 
Medicare beneficiaries,  providers, and suppliers of health care services 
can appeal certain decisions related to their Medicare claims.  
Currently, the Medicare administrative appeals process includes four  
levels. This  study focuses on the second level, QIC reconsiderations.   
Section 521 of the Medicare, Medicaid and SCHIP Benefits 
Improvement and Protection Act of 2000 (BIPA), P.L. No. 106-554, 
made significant changes to the Medicare claims  appeal process.1   
Among other things, it required that QICs conduct the second level of 
Medicare appeals, called reconsiderations, for Medicare Part A and 
Part B claims.2  The revised appeals process had a phased  
implementation, which took place in  fiscal years (FY) 2005 and 2006.  
The Centers for Medicare & Medicaid Services (CMS), the agency that 
oversees QIC operations, obligated about $40 million for QIC activities 
during this timeframe.3   Given the changes required by the BIPA, the 
Office of Inspector General (OIG) sought to determine whether QICs 
met processing requirements in the early phase of implementation from  
May 2005 to July 2006. 
Medicare Administrative  Appeal Process 
Medicare Part A provides coverage for institutional care, such as 
inpatient hospital care, skilled nursing facility care, home health 
services, and hospice care.  Medicare Part B provides coverage for the 
cost of noncustodial care, such as physician services, outpatient hospital 
services, and medical equipment and supplies.  Under Medicare  Parts A 
and B, a beneficiary can obtain health care services from any provider  
 
1  The BIPA  was later modified by sections 931, 933, 939, and 940 of the Medicare 

Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), P.L. No. 108-173.
    
2  42 U.S.C.  1395ff(c)(1) (as amended by BIPA,  521(a)).  

3  Budget estimates for FYs 2005 and 2006 provided to OIG by CMS.
  
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that is qualified and chooses to participate in the Medicare program.4   
Generally, to receive payment for the provision of health care services, 
the provider or beneficiary can submit a claim for payment to the  
appropriate Affiliated Contractor.5 For this report, the term Affiliated 
Contractor includes fiscal intermediaries (for all Part A claims and 
certain Part B claims) or carriers (for  most claims under Part B). If the 
Affiliated Contractor determines that the claim for medical care is not 
covered under Medicare because it is  invalid or incomplete  or otherwise 
appears to be improper, it denies the claim.6 When the Affiliated 
Contractor  denies a claim, it notifies the provider or beneficiary of the  
denial and offers the opportunity to appeal the denial.7    
There are four distinct administrative levels of appeal; 
   Level One: Affiliated Contractor redeterminations, 
   Level Two: QIC reconsiderations, 
   Level Three: Administrative Law Judge hearings, and 
   Level Four:   Medicare Appeals Council hearings. 
If these administrative appeal levels have been exhausted, appellants 
may bring their cases to a Federal district court. 
Qualified Independent Contractors 
CMS awarded four QIC contracts to  conduct Parts A and B 

reconsiderations for FYs 2005 and 2006. 

Part A  QICs.  On May 1, 2005, two QICs, First Coast Service Options 
(FCSO) and Maximus, began processing Part A reconsiderations.   
Part B QICs. On January 1, 2006, Quality2Administrators began 
processing Part B reconsiderations out of two separate locations 
(hereafter referred to as the Q2A East and the Q2A West). The Q2A  
East was responsible for Part B reconsiderations for 26 States, the 
District of Columbia, and 2 U.S. territories. The Q2A West was 
responsible for Part B reconsiderations for the other 24 States and 
 
4  42 U.S.C.  1395a. 
 
5  MMA (P.L. No. 108-173  911(d)) requires that Medicare Administrative Contractors 

(MAC) gradually assume the  work currently performed by  Affiliated Contractors, including 

fiscal intermediaries, carriers, and durable medical equipment regional carriers. CMS 

began replacing Affiliated Contractors in October 2005 and is expected to complete the 

transition by October 1, 2011 (42 CFR  421.400).
   
6  Social Security Act  1869. 
 
7  42 CFR  405.921(a)(2). 
 
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3 U.S. territories, as well as reconsiderations for durable medical 
equipment, prosthetics, and  supplies claims.8   
Separate from the reconsideration contracts, CMS also awarded a 
contract to the Q2A to provide administrative services in support of 
QICs. Hereafter, we refer to this contractor as the administrative QIC.    
Processing Requirements  
Timeliness requirements.  Pursuant to section 1869(c)(3)(C)(i) of the 
Social Security Act, QICs are required to render reconsideration 
decisions within 60 calendar days from the dates that they receive 
timely filed reconsideration requests and send written notices of the 
decisions to  the appellants.9  10   
Correspondence requirements.  In addition, pursuant to Federal 
regulations and/or QICs Umbrella Statement of Work, QICs  are 
required to  send appellants the following correspondence: 
 	   Acknowledgment Letters:  Within 14 calendar days of the receipt 
of a request, QICs must send the appellant written 
acknowledgment of  the appeal.11  The acknowledgment letter 
must inform the appellant that the appeal has been received  and  
provide instructions for obtaining further information.12     
 	   Reconsideration Decision Letters:  Within 60 days from the date of 
receipt of a reconsideration request, QICs must send a written 
letter notifying the appellant of the reconsideration decision.13   
 
8  For FY 2007, however, CMS restructured the Part B workload into three jurisdictions and 
recompeted the contracts among all QICs.  The Q2A South  (formerly  Q2A East) began 
handling Part B reconsiderations for 16 States and 2 U.S. territories; FCSO began 
processing Part B reconsiderations for 34 States, 3 U.S. territories, and the District of 
Columbia; and Rivertrust Solutions began processing all durable medical equipment 
reconsiderations.  
9  This report does not address expedited appeal reconsiderations, which have different 
processing timeline requirements (Social Security Act  1869(c)(3)(C)(iii)(I)). 
10  Under 42 CFR  405.970(b)(1) and (3), decision deadlines may be extended if the QIC 
grants an appellants request for an extension of the 180-day filing deadline and/or if a 
party to the reconsideration submits additional evidence after the request for 
reconsideration is filed.     
11  CMS, Qualified Independent Contractor Umbrella Statement of Work, section III.A.2, 
September 1, 2005.  
12  Ibid. 
13  Pursuant to 42 CFR  405.970(c)(1), QICs must  send appellants one of three documents 
within 60 days:  a decision letter, a dismissal notice, or an  option to escalate their case to 
the next level.  Our evaluation looked at whether QICs sent appellants any one of these 
documents within 60 days.     
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This letter must contain a statement indicating whether the 
decision is favorable or  partially favorable, i.e., when a QIC  
overturns prior appeal decisions, or  unfavorable, i.e., when a QIC  
upholds prior appeal decisions.  Other content requirements for 
this kind of notification include a summary of the facts in the 
case; an explanation of how pertinent laws, regulations, coverage 
rules, and CMS policies apply to the facts of the case; and  
information concerning the appellants right to an Administrative 
Law Judge hearing.14  If QIC decides to dismiss the appellants 
request for reconsideration, it  must send a letter notifying the 
appellant of the dismissal within 60 days from the date of receipt 
of the reconsideration request.15    
 	   Written Notification of Processing Delay and the Right to 
Escalate: If QIC fails to reach a decision within 60 days, it must 
send a written notice of the delay that offers the appellant the 
option to escalate the case to the Administrative Law Judge 
hearing level (these notifications must be sent within 60 days of 
receiving a reconsideration request).16  To trigger the escalation, 
the appellant must respond with a written request.17  However,  
for those cases in which the appellant does not request escalation, 
Federal regulations do  not set forth additional processing timeline  
requirements. 
Data entry requirements and the Medicare Appeals System. According to 
QICs Umbrella Statement of Work, CMS requires QICs to enter and 
track information regarding the disposition of each reconsideration in 
the Medicare Appeals System (the appeals system).18  The appeals 
system was originally designed to store and facilitate the transfer of 
case-specific data across the four  levels of administrative appeal.19 In 
September 2003, CMS contracted with CGI Federal to develop and 
 
14  42 CFR  405.976(b). 

15  42 CFR  405.970(c)(3). 
 
16  42 CFR  405.970(c)(2). 
 
17  If the appellant requests escalation, then, within 5 days, the QIC must either finish
  
processing the reconsideration or escalate the case to the Administrative Law Judge 
hearing level (42 CFR  405.970(de)). 
  
18  CMS, Qualified Independent Contractor Umbrella Statement of Work, Section II.A., 

September 2005. 

19  Department of Health and Human Services (HHS), Report to Congress:  Plan for the 

Transfer of Responsibility for Medicare Appeals, March 2004.  

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maintain the appeals system. Currently, Level Two and Level Three 
use the appeals system.20    
The appeals system contains many data fields, which CMS requires 
QICs to populate with accurate information from reconsiderations.21   
Administrative Law Judge staff can view QIC-entered reconsideration 
data in the appeals system for cases that progress to that hearing level.    
CMS Oversight 
According to CMS, it uses the following mechanisms to monitor and  
assess QIC performance:22   
Weekly reviews of Appeals System data. CMS analyzes information 
contained in the appeals system on a weekly basis to determine whether 
QICs are processing reconsiderations within 60 days and to ensure that 
QICs are sending required correspondence, such as acknowledgment 
and decision letters, to appellants. 
Annual onsite reviews. Each fiscal year, CMS representatives visit QICs 
to determine compliance with program requirements and to assess 
overall QIC performance. During what are typically 5-day visits, CMS 
reviews paper case files for a random sample of reconsiderations to 
determine whether:  acknowledgment letters were sent on time; decision  
letters were  sent on time; decision letters contained required  content,  
such as decision explanations and directions for filing further appeals; 
and case files contained complete information. CMS also reviews QIC 
decisions during the course of annual performance reviews.   Findings 
from these evaluations are compiled  in a written report.    
Quality assurance program. In addition to these mechanisms, CMS 
requires each QIC to have an internal quality assurance program, to 
include regular case reviews and an overall self-assessment. On an 
annual basis, QICs submit to CMS written reports summarizing 
self-assessment results. 
Related Work  
In January 2002, prior to the full implementation of the BIPA, OIG 
released a report that analyzed the potential impact of the BIPA on the  
 
20  Staff from CMSs Medicare Enrollment and Appeals Group reported that, as of 
December 2006, there were no current plans to implement the Medicare appeals system 
(the appeals system) at the remaining appeals levels. 
21  CMS, List of Required/Non Required Medicare Appeals System Fields, November 2005.  
22  OIG interview with staff from  CMSs Medicare Enrollment and  Appeals Group,  
December 2006.   
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Medicare administrative appeals process.23  OIG found, among  other 
things, that the former process for Administrative Law Judge appeals 
was backlogged and overwhelmed.  The  report recommended a 
modernization of the appeals process.  OIG also recommended that HHS 
develop a training program for all reviewers at all levels of appeals to 
ensure common knowledge, understanding, and information about the 
appeals process.  HHS concurred with these recommendations.   
In a report released in October 2004, the Government Accountability 
Office (GAO) evaluated HHSs and the Social Security 
Administrations (SSA) plan to transfer Administrative Law Judge 
hearings to HHS.24  25  GAO found that the plan generally fulfilled all of 
the elements mandated by the MMA, such as a timetable, cost  
projections,  and information about the development of a case-tracking 
system. However, the plan omitted important information,  such as 
specific transition milestones and contingency arrangements.  GAO 
recommended that HHS and SSA address these deficiencies.  In its 
response, HHS generally agreed with GAOs recommendations.   
In addition, OIG is currently reviewing the use of telephone, video, and  
in-person conferences to conduct Medicare Administrative Law Judge 
hearings. 
METHODOLOGY 
This study examines QICs performance in processing reconsiderations.  
Specifically, we determined whether QICs:  
 	  adjudicated reconsiderations within 60 days from the date of 
appeal requests by reviewing appeals system data for all 
reconsiderations opened from May 2005 to July 2006 for Medicare 
Part A cases and from January to July 2006 for Medicare Part B 
cases;26    
 
23  OIG, Medicare Administrative  Appeals:  The Potential Impact of BIPA,                     
OEI-04-01-00290, January 2002.   

24  Section 931 of the MMA required the transfer of the Medicare Administrative Law Judge 

hearing process from SSA to HHS. 
    
25  GAO, Medicare:  Incomplete Plan to Transfer Appeals Work Load from SSA to HHS 
Threatens Services to Appellants, GAO-05-45 (Washington, DC:  October 4, 2004).  
26  We used July 2006 as a cutoff to ensure that (1) QICs had at least 60 days to process a 
given reconsideration and (2) the  administrative QIC, which houses  reconsideration case  
files after disposition, had sufficient time to collect and submit requested case files.      
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 	  provided required case correspondence to appellants, based on our  
analysis of a random sample of reconsiderations adjudicated 
during the study period; and  
 	  entered accurate reconsideration information into the appeals 
system for five key data elements, based on our analysis of a 
random sample of reconsiderations adjudicated during the study 
period. 
Analysis of Appeals System Data  
Through CMS and the administrative QIC, we obtained data from the 
appeals system for all reconsideration requests initiated from 
May 2005 to July 2006.  We analyzed these data to determine the:  
 	  timeliness of QICs processing of reconsiderations; 
 	  characteristics associated with late reconsiderations, i.e., the 
number of days that the reconsiderations were late and the 
number of days associated with case file transfers from the 
Affiliated Contractors that handle redetermination appeals at 
Level One;   
 	  number of reconsideration requests received by each QIC; and 
 	  number of claims associated with reconsiderations.  
Case File Reviews 
From appeals system data, we identified all reconsiderations that were 
labeled as closed by the four QICs during the study period.27  From  
this population, we selected a random sample of 110 cases from each 
QIC, for a total of 440 cases.  We then contacted the administrative  
 
 
27  We defined closed cases as reconsideration cases in our specified sample timeframe that 
have dismissed, favorable,  partially favorable, or unfavorable decision findings in the 
appeals system.  
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QIC and requested the  corresponding case files for each sample case.    
We received a total of 423 case files.28  29    
We reviewed case file documentation to confirm whether QICs 
processed reconsiderations on time by determining the number of days 
between the date of receipt of the reconsideration request and the date 
of the reconsideration decision letter.   We also reviewed case files to  
determine whether documents showed that required correspondence, 
i.e., acknowledgment and decision letters and written notifications of 
processing delay (where  appropriate), were sent on time.  We labeled 
correspondence as missing if the case file did not contain supporting 
documentation.   
We also compared the information contained in the case files with data 
contained in the appeals system to determine the accuracy of data 
entered for five key elements.  We considered appeals system data to be 
inaccurate when it differed from information contained in the case files.  
Specifically, we examined whether the appeals system accurately 
reflected the:   
   appellant type; 
   date of receipt of the reconsideration request; 
   date of acknowledgment letter;  
   date of decision letter; and  
  reconsideration decision, e.g., dismissed, favorable, partially 
favorable, or unfavorable. 
Confidence intervals for estimates contained in this report are listed 
in Appendix A.    
 
28  The administrative QIC was unable to locate 2 files for FCSO, 1 file for Maximus, 10 files  
for Q2A East, and 3 files for Q2A West.  The administrative QIC reported that QICs do not 
develop case files under two circumstances:  (1) if the QIC establishes that the appeal is 
outside of its jurisdiction, it records the disposition as misrouted in the appeals system  
and forwards the request and associated materials to the QIC with jurisdiction; and (2) if a 
MAC redetermination appeal has not been conducted, the  QIC records the disposition as  
dismissed in the appeals system.  In  both circumstances, the QIC develops an appeals 
system record, but no case file.  
29  One of FCSOs  cases was an expedited appeal, which OIG did not include in the   
423 cases it reviewed. OIG had asked the administrative QIC to exclude all Part  A  
expedited cases.   According to the administrative QIC, the expedited case was not labeled 
appropriately in the appeals system, which explains its inclusion in our universe of cases.  
Our review  does not include Part A expedited reconsiderations because adjudication  
procedures differ from those of standard Part A  and Part B cases.   
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Structured Interviews  With QIC Staff 
We conducted structured interviews with QIC staff at FCSO, Maximus, 
and Q2A East. During these interviews, we spoke with managers, 
adjudication staff, and staff responsible for entering information into 
the appeals system. We also conducted a structured interview with 
management staff at Q2A West. We asked about the four QICs 
protocols for adjudicating reconsiderations and challenges that they 
experienced  with the reconsideration process.     
Structured Interviews  With Administrative Law  Judge Staff 
We conducted structured interviews with Administrative Law Judge 
teams in each of the four hearing offices within HHSs Office of 
Medicare Hearings and Appeals.30 Each Administrative Law Judge  
team included the primary docket clerk, one attorney, and one 
Administrative Law Judge. We asked Administrative Law Judge teams 
about their experiences in working with QICs, particularly as they 
related to the accuracy of the appeals system data entered by QICs. 
Structured Interviews  With CMS Staff 
We conducted structured interviews  with representatives from CMSs 
Medicare Enrollment and Appeals Group. We asked about the  
mechanisms that CMS uses to ensure QIC adherence to program  
requirements. 
Quality  Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency.  
 
30  The Office of Medicare Hearings and  Appeals is responsible for overseeing the 
Administrative  Law Judge hearing level process. During a hearing, an  Administrative Law 
Judge conducts  a new (de novo) review of  an appellants case and issues a decision based  
on the facts and  the law. The Chief  Administrative Law Judge leads the agency, which  
consists of four hearings offices, located in Arlington, Virginia; Cleveland, Ohio; Irvine, 
California; and Miami, Florida.  
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Part A Qualified Independent Contractors met  Based on our analysis of the 
the 60-day  processing timeframe; however,    appeals system data for all 
Part B contractors did not for 58 percent of  reconsiderations received from   
May 2005 to July 2006, both Part A 
reconsiderations  
QICs processed virtually all 
reconsiderations within 60 days, as required (see Table 1).31 However, 
Part B QICs did not meet timeframes for 58 percent of reconsiderations.  
Specifically, Q2A West did not process 74 percent of reconsiderations 
within 60 days and Q2A East did not process 40 percent of  
reconsiderations within 60 days.  Of these late decisions, Q2A Wests 
reconsiderations averaged 56 days late and Q2A Easts averaged  
21 days late. Our review of paper case files associated with a random 
sample of reconsiderations corroborated timeliness findings from our 
appeals system analysis.   
 
 
Table 1: Timeliness of Medicare Reconsideration Appeals Processed by  
Qualifie d Independent Contractors 
  Part A  QICs  Part B QICs 
  N=28,035  N=77,973 
 
 
Cases Not Meeting 60-Day Timeframes   < 1%  58% 
 
FCSO  Maximus  Q2A East   Q2A West  
    N=9,195  N=18,840  N=36,842  N=41,131 
 
Cases Not  Meeting 60-Day Timeframes  < 1%  < 1%  40%  74% 
 
 
Cases Open More Than 90 Days   0%  0%  12%  39% 
 
 
Average No. of Days Late  0  0  21  56 
 
Source:  OIG analysis of Medicare Appeals System data:  Part A, May 2005July 2006 and Part B,   
JanuaryJuly 2006. 
 
To address the Part B QICs performance issues, CMS took two key 
actions.  It placed both Part B QICs on improvement plans.  For  
FY 2007, CMS also restructured the Part B workload into three 
jurisdictions and recompeted the contracts among all QICs.  Although 
Q2A West was not awarded a contract to  conduct new appeals, CMS did 
extend its existing contract to handle approximately 
 
31  In our timeliness calculations, we took into account reconsideration extensions permitted 
under 42 CFR  405.970(b).   
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26,000 reconsiderations that were pending decisions. According to CMS 
officials, these reconsiderations were all completed by September 2007. 
Qualified Independent Contractors did not  Case correspondence, such as 
meet all correspondence requirements but  acknowledgment letters, late 
notices, and decision letters, serve 
did include the appropriate content in 
as important case updates and 
reconsideration decision letters 
notifications of appeal rights. 
Documents contained in case files do not substantiate that the four 
QICs sent all required correspondence, and some correspondence was 
not sent within required timeframes. QICs did, however, include all 
required  content in decision letters.    
Acknowledgment letters.  Twenty-six percent of QIC case files we 
reviewed were missing letters acknowledging appellants 
reconsideration requests, and 20 percent of case  files showed that these  
letters were sent after 14 days from the dates of receipt of the 
reconsideration requests. (See Table 2 on the next page.) The 
percentage of case files missing acknowledgment letters ranged from a 
low of 16 percent for Q2A West to a high of 37 percent for Maximus. 
Additionally, three QICs sent acknowledgment letters after required 
timeframes, ranging from a low of 8 percent of reconsiderations for 
Q2A East to a high of 37 percent for Q2A West. 
Reconsideration decision letters. Twelve percent of QIC case files were 
missing reconsideration decision letters, ranging from a low of 7 percent 
of reconsiderations for Q2A East to a high of 16 percent for Maximus. 
However, when present, QICs decision letters contained all required  
content, including the reconsideration decision; a summary of the facts 
in the case; an explanation of how pertinent laws, regulations, coverage 
rules, and CMS policies apply to the facts of the case; and the 
appellants right to an Administrative Law Judge hearing. 
Written notification of processing delay and the right to escalate. For late  
Part B reconsiderations, 40 percent  of case files were missing 
documentation substantiating that the Part B QICs sent notifications of 
processing delays to appellants by the 60th day following the receipt of 
their reconsideration requests, as required. Another 37 percent of case  
files for late Part B reconsiderations  show that these notifications were  
sent after 60 days. Such notifications serve to  make appellants aware of 
their right to escalate their cases to the Administrative Law Judge 
hearing level. 
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Table 2: Missing or Untimely Correspondence for Medicare Reconsideration Appeals 
  Processed by  Qualified Independent Contractors   
 
  Overall  Part A  QICs  Part B QICs 
 
    FCSO  Maximus  Q2A East   Q2A West  
 
   
       
Acknowledgment Letters   
 
               
    Missing Documentation  26%  26%  37%  33%  16% 
 
           
 Letters Sent After Required Timeframe  20%  0%  16%  8%  37% 
 
   
       
Reconsideration Decision Letters 
 
               
      Missing Documentation  12%  10%  16%  7%  14% 
   
  Written Notification of Processing         
Delay and the Right to Escalate 
     
   Missing Documentation  40%  N/A  N/A*  46%  37% 
        
   Notifications Sent After Required   
  Timeframe  37%  N/A  N/A  23%  43% 
Source:  OIG review of 423 Medicare reconsideration appeals case files:  Part A, May 2005July 2006 and Part B,  
                   
  JanuaryJuly 2006. 

*Maximus was missing documentation  substantiating that it sent  written notifications of processing delay to appellants for its two late 
 
decisions.  However, because  so few decisions were decided late, we were unable to report statistics for missing notifications of 

  processing delays with a reasonable level of confidence. 
 
Qualified Independent Contractors entered 
We reviewed a sample of paper case 
inaccurate information into the Medicare 
files to verify the accuracy of 
Appeals System for 54 percent of   information entered into the 
reconsiderations  appeals system by each QIC.  We 
found that, for the five items we 
reviewed, QICs entered inaccurate information in the appeals system 
for 54 percent of reconsiderations.32  (See Table 3 on the next page.)  
The five items we reviewed were:  appellant type; date of receipt of the 
reconsideration request; acknowledgment letter date; decision date; and 
 
32  As stated previously, we analyzed appeals system data to determine whether QICs 
processed reconsiderations within 60 days.  Although we found that QICs entered 
inaccurate information in the appeals system for the five items identified in this report, we  
were able to corroborate our findings regarding timeliness through the review of  paper case 
files associated with a random sample of reconsiderations.     
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decision type, i.e., dismissed, partially favorable, favorable, or 
unfavorable. 
Table 3: Percentage of Inaccuracies in Medicare Appeals System Data for 
Reconsideration Appeals Processed by Qualified Independent Contractors  
Information Reviewed   Overall   FCSO   Maximus   Q2A East   Q2A West  
Percentage of Cases With Any            
Incorrect Information  54%  15%  43%  60%  62% 
 
Appellant Type,  e.g., Beneficiary,  
Provider  11%  5%  14%  6%  16% 
 
Reconsideration Request Date   3%  2%  5%  4%  1% 
 
Acknowledgment Letter Date   18%  0%  28%  7%  27% 
 
Decision Date  33%  8%  6%  49%  38% 
 
Decision, e.g., Dismissed, 
Favorable, Partially Favorable, 
Unfavorable   3%  1%  4%  1%  4% 
Source:  OIG review of 423 reconsideration case files:  Part A, May 2005July 2006 and Part B,  
JanuaryJuly 2006.  
 
Specifically, we found that 11 percent of reconsiderations had the 
incorrect appellant types,33 3 percent had incorrect reconsideration 
request dates, 18 percent had incorrect acknowledgment letter dates,  
33 percent had incorrect decision dates, and 3 percent had the incorrect 
decision type. 
Administrative Law Judge teams  reported that reconsideration 
information entered by QICs is often inaccurate or missing.  
Specifically, Administrative Law Judges cited incorrect health 
insurance claim numbers, missing dates of service, inaccurate claims 
information, and incorrect appellant types.  Administrative Law Judges  
reported that they rely entirely on paper case files to conduct hearings,  
in part because they presume that the data contained in the  appeals 
system are unreliable.   
 
 
33  The appellant-type designation is important because it may affect adjudication 
procedures.  For example, QICs have special requirements for the content and the 
complexity of the language used in decision letters sent to beneficiary appellants.    
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Factors contributing to deficiencies in  Based on data obtained through 
timeliness, correspondence, and data entry   structured interviews with QICs 
and our analysis of appeals system 
include case transfer delays, unexpected case 
data, we identified three factors 
volume, and appeals system challenges 
that contributed to processing 
deficiencies.  These include delays in case file transfers from the 
Affiliated Contractors to QICs, a large and unexpected Part B 
reconsideration case volume, and functionality challenges with the 
appeals system.  As discussed below, CMS took steps to address some of 
these issues.    
Case transfer delays    
Three of the four QICs reported that lags in case file transfers from  
Affiliated Contractors at Level One affected reconsideration 
adjudication timeframes and their ability to complete other activities, 
such as entering data into the appeals system and reviewing case 
information to reach decisions.  According to appeals system data, QICs 
received redetermination paper case files an average of 14 days after 
QICs requests. These case file transfers occur within QICs 60-day 
adjudication timeframe, meaning that delays in case transfers reduce 
the amount of time that QICs have to process reconsiderations.  Indeed, 
appeals system data show that for 15 percent of late reconsideration 
decisions, QICs received case files after 30 days from the date of the 
request, leaving only 30 days to process reconsiderations.     
Part B case volume  
Part B QIC officials cited unexpected case volume as the primary reason 
for their inability to process cases on  time. Our analysis confirmed that 
as of July 2007, Part B QICs had received about 20 percent more cases 
than the assumptions identified in their contracts with CMS.34  35   
Beyond timeliness effects, Part B QIC officials also reported that case 
volume prompted them to reassign  quality review staff to process 
 
34  Case volume estimates were based on Q2A East and  Q2A West Business Proposals, dated  
December 8, 2005.   
35  Representatives from CMS and the Part B QICs reported that underestimated  case 
volume  may be  explained, in part, by CMSs  assumption that provider appellants would 
aggregate approximately  five claims under one appeal.  If multiple claims were aggregated 
under one appeal, QICs could  gain efficiencies by  producing fewer letters and entering less 
overall data into the appeals system.  However,  according to appeals system data, Part B 
reconsiderations involved an average of only 1.3 claims rather than the estimated five  
claims. CMS officials indicated that case volume assumptions were based on historical 
information from the former  hearing officer level of appeals, which handled the second level 
of Part B administrative appeals prior to the implementation of  BIPA.  
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incoming reconsideration requests and to adjudicate cases, and 
prevented support staff from entering required data into the appeals 
system. CMS officials reported that case volume estimates were 
adjusted for FY 2007.   
Medicare appeals system challenges 
All QICs reported that challenges related to the appeals system affected 
timeliness and overall workflow during the initial months of operation.  
Specifically, the appeals system was frequently unavailable or slow, did 
not have the ability to generate appellant correspondence, and/or did 
not support resource management activities.  Further, the appeals 
system did not interface with databases that contained claims 
information. Consequently, QIC staff needed to  manually enter  
claim-specific information, which was prone to human error. According 
to all four QICs, these appeals system issues prompted them to develop 
ancillary systems to generate letters, support workflow management, 
and gather claims data.  CMS worked with CGI Federal to address 
these issues. However, as of December 2007, the appeals system was 
still not capable of interfacing with Medicare claims systems, which 
each of QICs report as essential to ensure that claim-level information 
is valid for a given reconsideration. 
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During our review, the Part A QICs had been processing  
reconsiderations for 15 months and the Part B QICs for 7 months.   We 
found that, during this time, two QICs were not processing the majority 
of their Part B reconsiderations within 60 days, case files did not 
substantiate that QICs sent correspondence to appellants for all 
reconsiderations, and data entered by QICs in the appeals system were 
inaccurate.   CMS made several changes to improve the reconsiderations 
process, including facilitating some improvements in the appeals 
system, restructuring the Part B workload into three jurisdictions, and 
recompeting the contracts among all QICs.  Although these actions may 
have improved some areas of reconsiderations processing, given the 
deficiencies  cited in this report and the potential impact of these  
deficiencies  on the overall Medicare appeals process, we recommend  
that CMS: 
Take Further  Action To Ensure That QICs Meet Timeliness, 
Correspondence, and Data Entry Requirements 
CMS currently employs several mechanisms to monitor QICs, which 
include weekly reviews of the appeals system data and annual site visit 
reviews.  CMS may consider several options for augmenting these 
mechanisms to ensure that QICs  meet Federal requirements  for 
processing reconsiderations.  For example, CMS could add metrics, such 
as error rates, to its annual reviews  to further assess the extent to 
which QICs meet correspondence and data entry requirements.  In 
addition, to better ensure that appeals system data are accurate, CMS 
could validate these data during annual reviews.  CMS could also 
evaluate the costs and feasibility of enabling the appeals system to  
extract information from databases that contain claims data, thereby 
reducing the need for manual data entry.  Lastly, CMS could monitor 
the length of time that it takes Affiliated Contractors to transfer paper 
case files to  QICs, to better ensure that QICs have a reasonable number 
of days to adjudicate reconsiderations.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with our recommendation to take further action to 
ensure that QICs meet timeliness, correspondence, and data entry  
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requirements and outlined efforts it  has planned or has already taken to  
address it.  
In response  to our suggestion to consider adding metrics to its annual 
performance evaluations, CMS responded that, during annual 
evaluations of each QIC, it reviews a  sample of case files to determine a 
percentage of inaccurate decisions.  The percentage of inaccurate 
decisions found during the review is  then used to determine whether the  
QIC is eligible for a portion of the contract award fee.  However, we 
noted that performance evaluation review reports supplied by CMS did 
not contain errors specific to  correspondence and data entry 
requirements.  Given the extent to  which we found problems in these 
areas, we continue to recommend that CMS may consider adding 
metrics to gauge QICs performance related to correspondence and 
appeals system data entry.  Further, CMS reported that it augmented 
its review of QICs by awarding a contract to a private entity that will 
conduct its own performance evaluation to determine QICs adherence 
to Federal requirements.  To better ensure that appeals system data are 
accurate, the contractor will also validate the accuracy of appeals 
system data for the cases it selects, according to CMS.   
In response  to our suggestion that CMS work toward enabling the 
appeals system to  extract information from databases that contain 
claims data, CMS reported that it has developed such an interface.  This 
system change is scheduled to be implemented in July 2008.   
In response  to our suggestion that CMS monitor the length of time it 
takes affiliated contractors to transfer paper case files to QICs, CMS 
stated that it is reviewing weekly and/or monthly reports on  transfer 
timeliness, and uses this information as part of the affiliated 
contractors annual performance evaluation.  CMS reported that, as of 
May 2008, most affiliated contractors were meeting established 
timeliness standards for forwarding case files.  Looking forward, CMS 
indicated that it included financial incentives in its contracts with the 
new MACs to forward case files to  QICs within 4 days for 85 percent of 
cases.  
Finally, CMS noted that, subsequent to the time  period covered by our  
review, March 2005July 2006, it has made several changes to the 
second level  of Medicare appeals, which culminated in the award of 
three new Part B QIC contracts.  CMS reported that all three Part B 
QICs completed over 98 percent of reconsiderations on a timely basis 
during October 2007March 2008.  Although OIG has not independently 
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verified the supporting data, we have included a table that CMS 
provided, which outlines timeliness information for all three Part B 
QICs as part of the agencys comments.   
The full text of CMSs comments is provided in Appendix B. 
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  A P P E N D I X ~ A  
Point Estimates and Confidence Intervals  
 
Table 1:  Missing or Untimely Correspondence for Medicare Reconsideration Appeals 
Processed by  Qualified Independent Contractors  
   
 
   
    95-Percent 
Estimate Description  N  Estimate   Confidence Interval 
 
Overall Percentage of Case Files Missing 
Acknowledgment Letters   423  26.3%  21.830.8%  
 
Overall Percentage of Acknowledgment Letters Sent 
Late  423  20.0%  15.724.2%  
 
Overall Percentage of Case Files Missing Decision      
Letters  423  11.7%   8.315.0%  
 
Overall Percentage of Case Files Missing Written     
Notifications of Processing Delays   115  39.7%  30.748.9%  
 
Overall Percentage of Written Notifications of 
Processing Delays Sent Late  115  37.0%  28.045.5%  
Source:  Office of  Inspector General (OIG) review of 423  reconsideration  case files:  Part A, May 2005July 2006 and Part  B, JanuaryJuly 2006. 
 
 
 
Table 2: Estimate of Missing or Untimely Correspondence by  Part A Qualified Independent 
Contractors 
First Coast  Maximus 
 
N=107   N=109  
95-Percent   95-Percent  
Confidence  Confidence 
Estimate Description   Estimate   Interval  Estimate  Interval 
       
       
Missing Acknowledgment Letters   26.2%  17.834.6%   36.7%  27.545.9%  
         
 
       
Acknowledgment Letters Sent After 14 Days 
N/A  N/A  15.6%  8.722.5%  
         
Missing Decision Letters     10.3%  4.516.1%   15.6%  8.722.5%  
Source:  OIG analysis of 423 Medicare reconsideration appeals case files:  Part A, May 2005July 2006.  
 
   
 
 
 
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Table 3: Estimate of Missing or Untimely Correspondence by  Part B Qualified Independent 
Contractors  
Q2A East   Q2A West  
 
N=100  N=107 
95-Percent  95-Percent 
Confidence  Confidence 
Estimate Description  Estimate   Interval  Estimate  Interval 
       
       
Missing Acknowledgment Letters   33.0%  23.642.4%   15.9%  8.922.9%  
       
       
Acknowledgment Letters Sent After 14 Days  8.0%  2.713.3%   36.5%  27.445.6%  
       
Missing Decision Letters   7.0%  1.912.1%   14.0%  7.320.7%  
N=39  N=76  
 
Missing Documentation of Notifications of Processing 
46.2%  30.661.8%   36.8%  25.947.7%  
Delay  
Notifications of Processing Delay  Sent After Required 
23.1%  9.936.3%   43.4%  32.354.5 
Timeframe 
Source:  OIG analysis of 423 Medicare reconsideration appeals case files:  Part B, JanuaryJuly 2006.  
 
 
Table 4:  Estimate of Inaccuracies in Medicare Appeals System Data for 
Reconsideration Appeals Processed by Qualified Independent Contractors    
 
 
N=423 
 
 
    95-Percent 
Estimate Description  Estimate   Confidence Interval 
 
Overall Percentage of Cases With Any  Incorrect 
Information  53.6%  48.458.8%  
 
Overall Appellant Type Inaccuracies    11.2%  7.814.6%  
     
Overall Reconsideration Request Date Inaccuracies   2.7%  1.04.4% 
     
Overall Acknowledgment Letter Date Inaccuracies   18.1%  14.122.2%  
 
Overall Decision Date Inaccuracies  33.0%  28.138.1%  
 
Overall Decision Inaccuracies, e.g., Dismissed, 
Favorable, Partially Favorable, Unfavorable  2.6%  0.94.3% 
Source:  OIG review of 423 reconsideration case files:  Part A, May 2005July 2006 and Part B,  JanuaryJuly 2006. 
 
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, Part Qualified  
Table 5:  Estimate of Inaccuracies in Medicare Appeals System Data for  
Reconsideration Appeals Processed by Part A Qualified Independent Contractors 
 
 
First Coast  Maximus 
N=107   N=109  
     
    95-Percent    95-Percent 
    Confidence    Confidence 
Estimate Description   Estimate   Interval   Estimate  Interval 
 
Percentage of Cases With Any Incorrect Information  15.0%  8.121.8%   43.1%  33.752.5%  
 
Appellant Type, e.g., Beneficiary, Provider    4.7%  0.68.7%  13.8%  7.220.3%  
         
Reconsideration Request Date    1.9%  0.236.59%*   4.6%  0.68.6% 
         
Acknowledgment Letter Date Inaccuracies   N/A  N/A  27.5%  19.036.0%  
 
Decision Date Inaccuracies  7.5%  2.412.5%   5.5%  1.29.8% 
 
Decision Inaccuracies, e.g., Dismissed, Favorable, 
Partially  Favorable, Unfavorable   0.9%  0.025.10%*   3.7%  0.17.2% 
Source:  OIG review of 423 reconsideration appeals case  files:  Part A, May 2005July 2006. 
*Confidence interval calculated with an  exact method based on the binomial distribution. 
 
  
 
 
Table 6:  Estimate of Inaccuracies in Medicare Appeals System Data for 
Reconsideration Appeals Processed by Part B Qualified Independent Contractors    
 
 
Q2A East   Q2A West 
N=100  N=107 
     
    95-Percent    95-Percent 
Estimate Description    Confidence    Confidence 
Estimate   Interval  Estimate  Interval 
 
Percentage of Cases With Any Incorrect Information  60.0%  50.269.8%   61.7%  52.371.0%  
 
Appellant-Type Inaccuracies    6.0%  1.310.7%   15.9%  8.922.9%  
         
Reconsideration Request Date Inaccuracies   4.0%  0.17.9%  0.9%  0.00020.051%*  
         
Acknowledgment Letter Date Inaccuracies   7.0%  1.912.1%   27.1%  18.635.7%  
 
Decision Date Inaccuracies  49.0%  39.059.0%   38.3%  29.047.7%  
 
Decision Inaccuracies, e.g., Dismissed, Favorable, 
Partially  Favorable, Unfavorable   1.0%  0.025.45%*   3.7%  0.17.4% 
Source:  OIG review of 423 reconsideration case files:  Part B, JanuaryJuly 2006. 
*Confidence interval calculated with an  exact method based on the binomial distribution.   
 
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Agency Comments 
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A P P E N D I X ~ B  
 
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  A C K N O W L E D G M E N T S  
 
This report was prepared under the direction of Kevin K. Golladay, 
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office, and A. Blaine Collins, Deputy Regional Inspector 
General. 
Christi Macrina served as the team  leader for this study.  Other 
principal Office of Evaluation and Inspections staff from the Dallas 
regional office who contributed to the report include Susan C. Bowman 
and Anthony Guerrero-Soto; central office staff who contributed include 
Barbara Tedesco, Kevin Farber, and Scott Manley.  
 
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