Transcript 2nd Level Medicare Appeals

QIO
2nd Level Medicare Appeals
Presented by:
Cindy L. Reynolds, RHIA
6/4/2014
NYHIMA 79th Annual Conference
Part A: East and West
East
Includes Alabama, Arkansas, Colorado,
Connecticut, Delaware, Florida, Georgia,
Louisiana, Maine, Maryland, Massachusetts,
Mississippi, New Hampshire, New Jersey, New
Mexico, New York, North Carolina, Oklahoma,
Pennsylvania, Rhode Island, South Carolina,
Tennessee, Texas, Vermont, Virginia, Washington
DC, West Virginia and Territories of Puerto Rico
and Virgin Islands.
Part A: East and West
West
Includes Alaska, Arizona, California, Hawaii,
Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky,
Michigan, Missouri, Montana, Nebraska,
Nevada, North Dakota, Ohio, Oregon, South
Dakota, Utah, Washington, Wisconsin,
Wyoming and the Territories of American
Samoa, Guam and the Northern Mariana
Islands.
Appeals Process
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Appeal Received
Case Scanned or Uploaded into SQID
Triage
Appeal Review
Technical or Clinical Adjudication
Decision Letters
Case Closing
Appeal Request
• Valid Redetermination Appeal Request
Requirements:
– The beneficiary’s name
– Medicare Health Insurance Claim (HIC) number
– Those specific service(s) and item(s) for which the
redetermination was requested and the specific
date(s) of service
– The name and signature of the party or the
representative of the party.
– 42 CFR Section 405.944(b)
Appointment of Representative
• Appointment of Representative (AOR) form:
– Must be included with the Appeal Request if
anyone other than the beneficiary or the provider
are filing the request for a redetermination or
reconsideration.
– 42 CFR Section 405.952(b)(2)
Case File
• Case file supplied by MAC/AC
• RAC
Missing Documentation
• Medicare will pay for services that are reasonable
and medically necessary for the diagnosis or
treatment of a condition, illness or injury in the
beneficiary. (Section 1862 (a)(1)(A) of the Social
Security Act). When a provider requests a
reconsideration, all documentation to support
the services being appealed must be included
with the request for reconsideration. The
provider is responsible for providing sufficient
documentation to support that payment is due
and the services were medically necessary and
provided as billed. (42 CFR Section 424.5(a)(6)).
Types of
Appeals That I Perform
Part A
Inpatient Hospital
Home Health
Dismissals
AC Dismissals
Category III
Coding
Copay/Deductible
B of A
Imaging/Radiology
Pathology/Laboratory
Dismissals
AC Dismissals
Category III
Coding
Copay/Deductible
MUE
Drugs
Radiation/Chemotherapy/Infusion
Types of Dismissals
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Dismissals
AC Dismissals
– Missing Claim Element
– Untimely
Date Stamp (Calendar date/Julian calendar date)
The date stamp is a series of numbers (approximately 10-15 numbers in length).
124300902008202
Does not appear as the standard Gregorian date style.
12/21/2009
Date is based on the Julian Day Calendar.
This Julian Calendar date makes up only part of the stamped number series
RAC Demand Letter
FISS Screens
Date claim paid
Good cause arguments
Good Cause Arguments
• 40.1.3 - Conditions Which Establish Good Cause
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(Rev. 381, Issued: 11-26-04, Effective: 11-26-04, Implementation: 01-10-05)
Good cause may be found when the record clearly shows, or the party alleges and the record
does not negate that the delay in filing was due to one of the following:
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Circumstances beyond the individual’s control, including mental or physical impairment (e.g., disability, extended
illness), or significant communication difficulties;
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The death of the individual or his/her advanced age (advanced age is met automatically if the individual attains age 75
prior to the date services began in the contested claim);
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Incorrect or incomplete information about the subject claim furnished by official sources (SSA, CMS, or the FI) to the
individual, e.g., whenever a beneficiary is not notified of his/her appeal rights or the time limit for filing;
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Delay resulting from efforts by the individual to secure supporting evidence where the individual did not realize that
such evidence could be submitted after filing a redetermination;
Unusual or unavoidable circumstances, the nature of which demonstrate that the individual could not reasonably be
expected to have been aware of the need to file timely; or
Destruction by fire, or other damage, of the individual’s records when the destruction was responsible for the delay in
filing.
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NOTE: When the beneficiary’s claim is being handled by a representative of the beneficiary
– (§60.5.6), these conditions apply to the representative. For conditions which establish good cause for late filing by
providers or suppliers who are representing a beneficiary, see §60.75.
Good Cause Arguments
Providers, Physicians or Other Suppliers
240.4 - Conditions and Examples That May Establish Good Cause for Late Filing by Providers, Physicians, or Other
Suppliers
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(Rev. 695, Issued: 10-07-05; Effective: 05-01-05; Implementation: 01-09-06)
A. Conditions
Good cause may be found when the record clearly shows, or the provider, physician or other supplier alleges and
the record does not negate, that the delay in filing was due to one of the following:
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Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (CMS, the
contractor, or the Social Security Administration) to the provider, physician, or other supplier; or,
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Unavoidable circumstances that prevented the provider, physician, or other supplier from timely filing a request for
redetermination. Unavoidable circumstances
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Encompasses situations that are beyond the provider, physician or supplier’s control, such as major floods, fires,
tornados, and other natural catastrophes.
NOTE: Failure of a billing company or other consultant (that the provider, physician, or other supplier has
retained) to timely submit appeals or other information is NOT grounds for finding good cause for late filing.
The contractor does not find good cause where the provider, physician, or other supplier claims that lack of
business office management skills or expertise caused the late filing.
Inpatient Hospital Appeals
• Inpatient Hospital
– Inpatient versus Observation
– Medical Necessity
– DRG
Inpatient Service
General Rule
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Inpatient hospital care, rather than hospital outpatient care, is required only if the beneficiary's medical
condition, safety, or health would be significantly and directly threatened if care was provided in a less
intensive setting. For inpatient care, the medical record must indicate that inpatient care was medically
necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time
during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the
need the need for medical care and must receive services of such intensity that they can be furnished
safely and effectively only on an inpatient basis. (Medicare Program Integrity Manual, Publication 100-8,
Chapter 6, Section 6.5.2)
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For inpatient hospital care, admitting physicians or other practitioners should use a 24-hour period as a
benchmark, i.e., they should order inpatient admission for patients who are expected to need such care
for 24 hours or more, and treat other patients on an outpatient basis. However, the decision whether to
admit as an inpatient is a complex medical judgment, which includes consideration of a variety of factors,
including:
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The patient’s medical history and current medical needs;
The types of facilities available to inpatients and outpatients, the hospital’s bylaws and admission policies,
and the relative appropriateness of treatment in each setting;
The severity of the signs and symptoms exhibited by the beneficiary;
The medical probability of something adverse happening to the beneficiary;
The need for diagnostic studies that are appropriately outpatient services to assist in assessing the need
for inpatient admission; and
The availability of diagnostic procedures at the time when and at the location where the beneficiary
presents.
(Medicare Benefit Policy Manual, Publication 100-2, Chapter 1, Section 10).
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Inpatient Care vs. Observation
• General Rule
• Outpatient observation care is a well-defined set of specific,
clinically appropriate services, which include ongoing short term
treatment, assessment, and reassessment before a decision can be
made regarding whether a patient will require further treatment as
a hospital inpatient, or if s/he can be discharged from the hospital.
Thus, a patient receiving hospital observation services may improve
and be released, or be admitted as an inpatient. In the majority of
cases, the decision whether to admit as an inpatient or discharge
can be made in less than 48 hours, usually in less than 24 hours.
(Medicare Benefit Policy Manual, Publication 100-2, Chapter 6,
Section 20.6; Medicare Claims Processing Manual, Publication 1004, Chapter 4, Section 290).
DRG’s
A Diagnosis-Related Group (DRG), as described by the Official Guidelines
for Coding and Reporting, is a system to classify hospital cases into one of
approximately 500 groups, also referred to as DRGs, expected to have
similar hospital resource use and developed for Medicare as part of the
prospective payment system. DRGs are assigned by a "grouper" program
based on International Classification of Diseases (ICD) diagnoses,
procedures, age, sex, and the presence of complications or co-morbidities.
In determining the DRG, the principal diagnosis is considered, which is
defined by the Uniform Hospital Discharge Data Set (UHDDS) as, “that
condition established after study to be chiefly responsible for occasioning
the admission of the patient to the hospital for care.” The admitting
diagnosis, administered treatments or procedures and secondary
diagnoses, defined by UHDDS as, “all conditions that co-exist at the time
of admission, that develop subsequently, or that affect the treatment
received and / or the length of the hospital stay,” are also utilized in the
assignment of the DRG to a claim. (U.S. Department of Health and Human
Services, Classification of Diseases, 9th Revision).
Home Health Appeals
• Home Health
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Plan of Care
Certification
Physician Orders
Face to Face Encounter
OASIS
Homebound vs. Not Homebound
Skilled Nurse Progress Notes
Therapy (PT, OT, ST) Progress Notes
Advance Beneficiary Notice
Home Health
General Rule
To qualify for Medicare coverage of home health services, a beneficiary must meet each of the
following requirements:
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Confined to the home;
Under the care of a physician;
In need of skilled services - the beneficiary must need at least one of the following skilled services
as certified by a physician in accordance with the physician certification and re-certification
requirements for home health services:
Intermittent skilled nursing services that meet the criteria of skilled services;
Physical therapy services that meet the criteria of skilled services;
Speech-language pathology services that meet the criteria of skilled services; and
Continuing occupational therapy services that meet the criteria of skilled services if the
beneficiary's eligibility for home health services has been established by virtue of a prior need for
intermittent skilled nursing care, speech-language pathology services, or physical therapy in the
current or prior certification period.
Under a plan of care;
By whom the services must be furnished - the home health services must be furnished by, or under
arrangements made by, a participating Home Health Agency (HHA).
(42 Code of Federal Regulations Section 409.42).
Home Health
Plan of Care and Certification
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The plan of care certifies that the home health services were furnished while the
individual was under the care of a physician who is a doctor of medicine,
osteopathy, or podiatric medicine. The certification of need for home health
services must be obtained at the time the plan of treatment is established or as
soon thereafter as possible and must be signed by the physician who establishes
the plan. The orders on the plan of care must indicate the type of services to be
provided to the patient, including the type of professional who will provide the
services, the nature of the services or tasks to be provided, as well as the
frequency of the services. When services are furnished based on a physician's oral
or verbal order, the orders must be signed and dated with the date of receipt by
the registered nurse or qualified therapist or medical social worker responsible for
furnishing or supervising the ordered services. Oral orders must be countersigned
and dated by the physician before the home health agency bills for the care in the
same way as the plan of care. The plan of care must be reviewed and signed by
the physician who established the plan of care at least every 60 days. Each review
of a patient's plan of care must contain the signature of the physician and the date
of review. (42 Code of Federal Regulations Section 424.22; Medicare Benefit Policy
Manual, Publication 100-2, Chapter 7, Section 30.2).
Home Health
Homebound vs. Not Homebound
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In order to meet Medicare criteria for coverage of home health services, the physician must certify that the
beneficiary is confined to his or her home. An individual does not have to be bedridden to be considered
confined to the home. However, the condition of the beneficiary should be such that there exists a normal
inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
(Medicare Benefit Policy Manual, Publication 100-2, Chapter 7, Section 30.1.1).
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Generally speaking, a beneficiary will be considered to be homebound if he or she has a condition due to an
illness or injury that restricts the ability to leave their place of residence except with the aid of: supportive
devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of
another person; or if leaving home is medically contraindicated. If the beneficiary does in fact leave the home,
the beneficiary may nevertheless be considered homebound if the absences from the home are infrequent or for
periods of relatively short duration, such as attending a religious service, or are attributable to the need to
receive health care treatment. Absences attributable to the need to receive health care treatment include, but
are not limited to:
• Attendance at adult day centers to receive medical care;
• Ongoing receipt of outpatient kidney dialysis; or
• The receipt of outpatient chemotherapy or radiation therapy.
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(Medicare Benefit Policy Manual, Publication 100-2, Chapter 7, Section 30.1.1).
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The appellant is responsible for providing the information necessary to establish that the beneficiary is
homebound as defined above. (Medicare Benefit Policy Manual, Publication 100-2, Chapter 7, Section 30.1.1).
B of A
• Imaging/Radiology
– Must have Physician Order
– Must have Imaging/Radiology Result
– Must have History and Physical prior to date of
service
– Look up National Coverage Determination (NCD)
– Look up Local Coverage Determination (LCD)
B of A
• Laboratory/Pathology
– Must have Physician Orders
– Must have Laboratory/Pathology results
– Look up National Coverage Determination (NCD)
– Look up Local Coverage Determination (NCD)
– Looking at covered diagnoses
– Supporting documentation (history and physical,
progress note, or other documentation)
MSP Appeals
• MSP (Medicare as Secondary Payer)
– Malpractice
– Wrongful Death
– Motor Vehicle Accident
– Worker’s Compensation
– Estate
– Law suits for Asbestos
– Unrelated Charges
– Wavier
MSP
• Wavier
When a primary payer makes payment to the beneficiary,
Medicare has the right to recover from the beneficiary the
primary payment made by Medicare, reduced by a
proportionate share of the beneficiary’s procurement costs
in obtaining the insurance payment, if any. However,
Medicare may waive its right to recovery when the
beneficiary meets certain criteria. A waiver may be granted
with respect to a beneficiary who is without fault when
adjustment or recovery would either defeat the purpose of
Title II or Title XVIII of the Social Security Act or would be
against equity and good conscience (Social Security Act
Section 1870(c); Medicare Secondary Payer Manual,
Publication 100-5, Chapter 7, Sections 50.5.4 and 50.6.2).
MSP
Wrongful Death
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Wrongful death statutes are State laws that permit a person’s survivors to assert the claims
and rights that the decedent had at the time of death. These laws may include recovering for
the deceased’s medical expenses. When a liability insurance payment is made pursuant to a
wrongful death action, Medicare may recover from the payment only if the State statute
permits recovery of these medical expenses. Generally, if the statute permits recovery of the
deceased’s medical expenses, Medicare may pursue its payments, even if the action fails to
explicitly request damages to cover medical expenses. Thus, in that event, even if the entire
cause of action sets forth only the relatives and/or heirs damages and losses, then Medicare
may still recover its payments. (Medicare Secondary Payer Manual, Chapter 7, Section
50.5.4.1.1).
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When State law permits a full recovery of medical damages but limits the amount of the
recovery which is payable to creditors as a result of past medical expenses, Medicare may
recover against the entire recovery, up to the full amount of past Medicare payments.
However, when State law limits the amount of the past medical expenses that may be
recovered from the defendant and responsible insurer, Medicare may recover only up to that
amount (or the amount of the settlement, if the settlement is less than or equal to
Medicare’s claim.) (Medicare Secondary Payer Manual, Publication 100-05, Chapter 7,
Section 50.5.4.1.1).
MSP
Estate
A beneficiary’s death does not materially change Medicare’s
interest in recovering its payments made on behalf of the
beneficiary while alive. Upon death, the estate of the beneficiary
comes into existence by operation of law. An executor or
administrator’s sole purpose is to conclude all business and
financial matters that still remained at death. Medicare’s interest in
the outcome of a third-party liability claim is one of these matters.
Therefore, Medicare’s claim is properly asserted against the estate.
The right to request a waiver and/or appeal applies equally to the
estate if there is a surviving spouse or other eligible dependent
under the Social Security Act. Where neither of these parties exists,
a waiver may not be granted. (Medicare Secondary Payer Manual,
Publication 100-05, Chapter 7, Section 50.5.4.1).
MSP
Worker’s Compensation
Medicare is secondary to worker’s compensation plans
(including black lung benefit programs). Payment under
Medicare may not be made for any items and services to
the extent that payment has been made or can reasonably
be expected to be made for such items or services under a
workers' compensation law or plan of the United States or
any State. If it is determined that Medicare has paid for
items or services that can be or could have been paid under
worker’s compensation, the Medicare payment constitutes
an overpayment. (Medicare Secondary Payer Manual,
Publication 100-05, Chapter 1, Section 10.4).
MSP
No-fault Insurance
If medical services are covered under a no-fault insurance, that insurance
must be billed first. If the insurer does not pay all of the charges, a claim
for secondary Medicare benefits can be submitted. Medicare can pay for
services related to an accident if benefits are not available under the
individual's no-fault insurance coverage because that insurance has paid
maximum benefits for the accident on items or services not covered by
Medicare or on non-medical items such as lost wages. If there is an
indication that the individual has filed, or intends to file, a liability claim
against a party that allegedly caused an injury, Medicare Secondary Payer
liability provisions may apply. Medicare has a right of recovery from the
no-fault insurance, as well as any entity that has received payment directly
or indirectly from the proceeds of a no-fault insurance payment.
(Medicare Secondary Payer Manual, Publication 100-5, Chapter 2, Sections
60 and 60.1).
MSP
General Rule
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In general, payment under Medicare may not be made for any items of services to
the extent that payment has been made or can reasonably be expected to be
made promptly under worker’s compensation, no-fault, or liability insurance.
Medicare’s liability for payment in this situation is secondary to that of the primary
payer. This exclusion is called the Medicare Secondary Payer (MSP) rule. If it is
uncertain whether an insurer will pay, Medicare will make a conditional payment.
This payment will be recovered later if it is determined that Medicare’s liability is
secondary to that of the primary payer. (Section 1862(b)(2)(B) of the Social
Security Act; 42 Code of Federal Regulations Section 411.32(a); Medicare
Secondary Payer Manual, Publication 100-05, Chapter 1, Section 10.7.1).
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Medicare has a right of action to recover conditional payments from any entity
(including beneficiaries, providers, attorneys, state agencies, or private insurers)
that has received primary payment. The Medicare Secondary Payer Manual
defines “primary payment,” in the context where Medicare is the secondary payer,
as “payment by a primary payer for services that are also covered under
Medicare.” (42 Code of Federal Regulations Section 411.24; Medicare Secondary
Payer Manual, Chapter 1, Section 20).
MSP
General Rule – Liability Insurance
• Medicare has a right of recovery from the liability
insurance as well as any entity that has received
payment directly or indirectly from the proceeds of a
liability insurance payment. Medicare's recovery right
is superior to other entities, including Medicaid,
because Medicare’s direct right of recovery is explicitly
prescribed in Federal law and other entities’ recovery
rights are based on either State law or subrogation
rights. (Medicare Secondary Payer Manual, Publication
100-05, Chapter 2, Section 40.1).
Medicare 3 Day Payment Window
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SEC.Social Security Act 1886. [42 U.S.C. 1395ww] (a)(1) (4) For purposes of this
section, the term “operating costs of inpatient hospital services” includes all routine operating
costs, ancillary service operating costs, and special care unit operating costs with respect to
inpatient hospital services as such costs are determined on an average per admission or per
discharge basis (as determined by the Secretary), and includes the costs of all services for which
payment may be made under this title that are provided by the hospital (or by an entity wholly
owned or operated by the hospital) to the patient during the 3 days (or, in the case of a hospital
that is not a subsection (d) hospital, during the 1 day) immediately preceding the date of the
patient’s admission if such services are diagnostic services (including clinical diagnostic laboratory
tests) or are other services related to the admission (as defined by the Secretary). Such term does
not include costs of approved educational activities, a return on equity capital, other capital-related
costs (as defined by the Secretary for periods before October 1, 1987), or costs with respect to
administering blood clotting factors to individuals with hemophilia. In applying the first sentence of
this paragraph, the term “other services related to the admission” includes all services that are not
diagnostic services (other than ambulance and maintenance renal dialysis services) for which
payment may be made under this title that are provided by a hospital (or an entity wholly owned or
operated by the hospital) to a patient—
(A) on the date of the patient’s inpatient admission; or
(B) during the 3 days (or, in the case of a hospital that is not a subsection (d) hospital, during the 1
day) immediately preceding the date of such admission unless the hospital demonstrates (in a form
and manner, and at a time, specified by the Secretary) that such services are not related (as
determined by the Secretary) to such admission.
Signature Requirements
• For medical review purposes, Medicare
requires that the services provided/ordered
be authenticated by the author. The method
shall be a handwritten or electronic signature.
(Medicare Program Integrity Manual,
Publication 100-8, Chapter 3, Section 3.3.2.4).
For Ordering Diagnostic Tests
• The rules in 42 CFR 410 and Pub. 100-02, chapter 15, section 80.6.1,
state that if the order for the clinical diagnostic test is unsigned,
there must be medical documentation by the treating physician
(e.g. a progress note) that he/she intended the clinical diagnostic
test be performed. This documentation showing the intent that the
test be performed must be authenticated by the author via a
handwritten or electronic signature.
• All documentation submitted by the provider should be complete
and identifiable as to who received the services billed and rendered
the services, and where and when the services were rendered. All
entries must be legible and complete, and must be authenticated
and dated promptly by the person (identified by name and
discipline) who is responsible for ordering, providing, or evaluating
the service furnished. Refer to 42 CFR Section 482.24 (c)(1).
CMS Guidance for Signatures
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- A written signature may be received via hard copy mailed correspondence or as
part of an appeal request submitted via facsimile.
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- An electronic, digital, and/or digitized signature is an acceptable signature on a
request submitted via a CMS-approved secure Internet portal/application. The
secure Internet portal/application shall include a date, timestamp, and statement
regarding the responsibility and authorship related to the electronic, digital,
and/or digitized signature within the record. At a minimum, this shall include a
statement indicating that the document submitted was, “electronically signed by”
or “verified/approved by” etc.
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- A stamp signature or other indication that a “signature is on file” on the CMS
20027 form or other documentation (such as a blank claim form) submitted to
support the appeal request shall not be considered a acceptable/valid signature
regardless of whether the appeal request is submitted via hard copy mail or via
facsimile.
Medicare Claims Processing Manual, Publication 100-4, Chapter 29, Section 310(b)(3)
Radiation/Chemo/Infusion
• Medicare requires documentation to validate services
were performed as billed and medically necessary.
Dosimetry calculations are coverable when there is
documentation to support independent calculations
are necessary and ordered by the treating physician. It
is usually not appropriate to report this service for
calculations that are part of a computerized plan. The
reviewed documentation shows stereotactic body
radiation therapy (SBRT) was planned for the treatment
of lung cancer. No dosimetry reports or treatment
planning notes to validate the number of dosimetry
calculations and number of beams or arcs were
included with the documentation sent for review.
Medically Unlikely Edits
• Medicare established the Medically Unlikely Edit (MUE) program in 2007
to reduce the paid claims error rate for Medicare claims. MUEs are
designed to reduce errors due to clerical entries and incorrect coding. An
MUE is defined as the maximum number of units of service under most
circumstances that a provider would report for a procedure or medication
for a single beneficiary on a single date of service. All codes do not have
an MUE. CMS publishes most MUE values on its website. However, CMS
does not publish MUE values for some codes. The MUE values for this
latter group of codes are confidential information. The published values
may be viewed on the CMS Website at:
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version
Update Changes.html.
• An MUE is an automated prepayment edit. Additional information on this
may be found in the Internet-Only Manual (IOM) Publication 100-8,
Medicare Program Integrity Manual, Chapter 3, Section 3.3.1.2 (B).
Questions
?
Contact Information
Cindy L. Reynolds
Appeals Officer, Technical Adjudicator
Maximus Federal Services
3750 Monroe Avenue, Suite 700
Pittsford, New York 14534-1302
Office: 585-348-3372