Transcript Medicare_Appeals_Process_10_07

Medicare Claims
Appeal Procedures
Lisa Bazemore
Director of Consulting Services
Objectives
• Review and clarify the steps of the Medicare Appeal
Process
• Offer suggestions to assist you to ‘efficiently and
effectively’ follow the process with as little confusion as
possible
• Assist you to resolve your claims successfully
• Introduce you to the eRehabData’s new tracking system
for denials
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Levels in Medicare Appeals Process -
• Additional Development Request
 Fiscal Intermediary determines whether or not to pay the claim.
• Redetermination
 FI considers their original determination based on your appeal.
• Reconsideration
 The Qualified Independent Contractor considers your appeal.
• Hearing
 The Administrative Law Judge hears your appeal.
• Review
 The Medicare Appeals Council/Department of Appeals Board will
review the decision of the ALJ.
 Next, the Federal District Court will hear you case on disputed
claims.
*The Medicare Appeals Process is the same for Medicare A and Medicare B
claims
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Reasons for Record Review
• The following list indicates common reasons for Medicare
requests for record review:
 Coding issues – CPT codes, ICD-9 codes
 Local Coverage Determination stipulations
 Probes – medical necessity
 Utilization issues or Fiscal Intermediary edits
 Billing error issues
 New provider number
 Change in ownership
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Step 1 – The ADR
• The ADR is a written request from the FI for a medical
record which will be reviewed before payment is
rendered.
• Tips:
• Documentation is time sensitive
• Note the source of the document
• Note the reason for the request if one is given
• Application:
 The FI will use the documents to determine if the claim
satisfies the Medicare requirements for payment.
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Step 1-ADR Process
• After you have carefully reviewed the FI correspondence:
 Pull the Summary Part A Appeal Process Checklist from
the AMRPA website.
 Review the list of suggested records to return. Be sure
each item is in the copies that you will submit.
 Alert HIM, billing, finance.
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Step 1-ADR Process
• After you have carefully reviewed the FI correspondence:
 Follow the directions from the fiscal intermediary
completely.
• Once the record is copied review it again for
completeness and accuracy.
• Be sure that each page is copied front and back.
• Make a copy of the packet prior to sending it to the FI so
you know exactly what the FI had for review.
 Send the record to the FI contact as provided on the
letter using a delivery method that offers a tracking
number.
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Initial Determination
• Notes about the FI’s determination:
 FI should respond within 30 - 60 days.
 Business Office Manager will receive an explanation of
the determination via the facility’s electronic billing
system.
• Be aware:
 You have 120 days from the date of receipt of the
notice. This is presumed to be 5 days after the date of
the notice.
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RAC Exception
• RAC Process:
 Charts will be requested and reviewed
 Determination will be rendered and sent to the
provider
 The provider has 15 days to rebut the decision of the
RAC before the RAC can request funds from the FI
 The RAC will consider the rebuttal
 If payment is denied, they will notify the FI
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RAC Exception
• Appeal
 Your claim is not a denial until the RAC requests funds
from the FI.
 The provider will have 120 days to appeal the decision
from the date of the remittance advise.
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Step 2 - Redetermination
• The Initial Appeal
 If the FI does not believe that your documentation
meets their criteria for payment, you will receive
notification that the claim was denied.
 At this stage you will send your record back to the FI
with a cover letter stating why you believe this claim
should be paid.
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Step 2 - Redetermination
• The appeal letter
 The body of the appeal letter should contain the following
information:
• Discuss the reason for the appeal
• Support the medical necessity of the claim
• Explain that the admission was appropriate for your
level of care and services were reasonable and
necessary
• Defend each week of care
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• Cite specific Medicare regulations such as the
conditions of participation in your letter where
applicable
Appeal letter
• Open the letter stating:
 Request re-determination of the claim
 The reason for the denial as stated on the original
correspondence from the FI
• Utilize the body of the letter to refute the stated reason for
the denial
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Appeal letter
• Historical information:
 Pertinent medical history
 Co-morbidities that support decision to admit, interventions,
and length of stay
 Reason for referral to inpatient rehabilitation
 Specific and pertinent prior level of function
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Appeal Letter
• Example:
In summary, Mr. Patient was admitted to Example Rehabilitation
on xx/xx/xx through xx/xx/xx following an acute care stay at
Example Medical Center after experiencing tremors, generalized
weakness and decreased food and liquid intake which led to
dehydration and weakness. In addition to these acute issues, Mr.
Patient has several underlying medical conditions. Following case
review by the intake assessment team, it was felt he was
appropriate for a comprehensive rehabilitation program due to his
decline in functional status.
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Mr. Patient received a comprehensive, interdisciplinary
rehabilitation program including rehabilitation nursing, physical
therapy, occupational therapy, and medical social work,
psychology, clinical dietician, wound care and therapeutic
recreation services. Formal team conference led by a physician
occurred on a weekly basis to ensure a coordinated program of
care. Mr. Patient participated in an intense individual and group
therapy program that allowed him to achieve his established
goals. He was discharged safely to home on xx/xx/xx.
Appeal letter
• Reason for inpatient rehabilitation services:
 State findings on pre-admission screening that led to
decision to admit.
 Include a review of assessments: H&P, therapy and nursing
evaluations.
 Indicate goals.
 Definitely state why patient requires inpatient rehab to meet
goals.
 State interventions and how these support need for inpatient
rehab.
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Appeal Letter
• Example:
Mr. Patient required the 24-hour availability of a physician with
special training or experience in the field of rehabilitation as
evidenced by Dr. Other Doctor’s frequent, direct, and medically
necessary involvement in his care.
06/27/2006 – Initial assessment and establishment of plan of
care completed by Example, P.A., dictating for attending
physician Dr. Other Doctor, as per the history and physical
located on pages 15 to 19. The history and physical along with
the admission orders found on pages 42 to 44 detail the need for
a rehab physician to coordinate and monitor the integrated
interdisciplinary rehabilitation program for decline in functional
status after alcohol withdrawal with acute delirium tremens,
management of hypertension, wound care, pneumonia and
prevention of deep venous thrombosis. The individual’s overall
medical condition and medical needs identified a risk for medical
instability requiring monitoring and involvement by the physician
that is generally not available outside the hospital inpatient
setting.
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Appeal Letter
• Example continued:
06/28/06 – Dr. Doctor, who was covering for Dr. Other Doctor, saw the patient and
assessed his vital signs, lungs, heart, extremities, and laboratory data. He
indicated continued management of deep venous thrombosis prophylaxis,
chronic atrial fibrillation, hypertension, stage II pressure ulcer on sacrum,
treatment for pneumonia, hypothyroidism. He also included consideration for
speech therapy consult in the plan. His note can be found on pages 69 and 70
and resulting orders on pages 36 and 37.
06/29/06 – Mr. Patient was seen by Example, P.A. and Dr. Other Doctor. They
assessed his vitals, lungs, abdomen, heart and extremities. The discussed his
diagnosis of gout and the intended course of treatment. The note on page 68
indicates continued treatment for rehab and medical issues. Orders can be
found on page 35.
06/30/06 - Dr. Another Example saw the patient and assessed his new onset
back pain, vital signs, lungs, heart, abdomen, extremities and lab results. Plan
to continue established treatment with trial of medications for back pain. The
note can be found on pages 60 and 61 with resultant orders on page 35.
Etcetera for each day of the stay that reflects medical decision-making
The frequent interventions and coordination of care by a physiatrist could not
have been provided at a lower level of care, specifically at a skilled nursing
facility or by a home health agency.
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Appeal letter
• Summary of progress:
 For each goal or category of goal (I.e. mobility) state status
at referral, status according the admission assessment, and
status at discharge.
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Appeal Letter
24 Hour Rehabilitation Nursing Example:
Rehabilitation nursing was ordered for Mr. Patient at the time of admission
for bowel and bladder FIM assessment with bowel/bladder program PRN,
vital sign monitoring twice a day, monitoring of weight, activity, wound
prevention and deep vein thrombosis prevention. See admission orders
on page 44.
On 06/28/2006 nursing completed their assessment and initiated a care
plan to address risk of injury, impaired skin integrity, knowledge deficits
and ineffective breathing pattern. Details of the rehab nursing plan of
care can be found on pages 93 and 94. Nursing also initiated the
Pressure Ulcer Prevention protocol, which can be found on page 38, due
to Mr. Patient’s significant risk of developing a pressure ulcer.
In ordering rehabilitation nursing at Example Rehabilitation, Dr. Other
Doctor was aware that nursing would perform daily assessment and
intervention on fall risk, neurological checks, psychosocial status,
respiratory status, cardiovascular status, gastrointestinal status, renal
status, bowel and bladder status, mobility, wound care, pain, safety and
intake and output monitoring. Assessment and intervention on these
items can be found in the daily nursing documentation on pages 95 to
227. Additional rehab nursing interventions can be found in the daily
nursing narratives on pages 106, 130, 154, 160, 166, 172, 196 and 202.
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Appeal Letter
• 24 Hour Rehabilitation Nursing Continued:
Additionally Dr. Other Doctor knew that the rehab nurse would provide education
to the patient and family on the areas assessed as appropriate. The
interdisciplinary education tracker can be found on pages 393 to 394. The
education tracker indicates a rehab nurse provided education on advanced
directives, patient rights and responsibilities, diagnosis, plan of care, pain
management, nutrition/diet/oral health, self-care, rehab techniques, and
current medications. On 07/14/2006 the rehab nurse provided discharge
instructions to the patient including diet, bowel/bladder, skin, activity level and
restrictions, return appointments, and medications. This education is detailed
on page 87 to 88 of the nursing discharge instructions.
The frequent assessment and interventions by an RN that were utilized throughout
the 24 hour period as well as the specialized patient and family education could
not have been provided in a less intensive setting.
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Appeal Letter
• Relatively Intense Level of Rehabilitation Services Example:
Mr. Patient’s need for an intense level of rehab services was indicated
by the ordering of therapies in the admission orders on page 43. As
a standard of care at Example Rehabilitation patients are to receive
3 hours of therapy 5 days a week unless otherwise ordered. Please
see the Appendix A attached to this request for redetermination. Per
recommendation from *** FI, Example Rehabilitation monitors
minutes of therapy delivered to the patient per week. Minutes
monitored include services provided from physical, occupational and
speech therapies as well as any provision of care from an orthotist or
prosthetist. An intense level of rehabilitation services is supported
by the delivery of a minimum of 900 minutes per 7 day period, or an
average of 129 minutes per day. Mr. Patient received more than 900
minutes of therapy in the first two weeks of his stay. On the last
three days of his stay he received greater than 180 minutes per
days. These findings indicate compliance with the 3 hour care plan
and that an intense level of rehabilitation services was provided.
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Appeal letter
• End with a summary:
Reason for referral
Prior level of function
Skilled interventions
Functional progress in spite of complicating conditions
Statement of potential outcomes if patient was not seen in inpatient
rehab setting
 Formally request re-determination
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Appeal Letter
• Example Summary:
During Mr. Patient’s stay, he required and received a comprehensive
interdisciplinary rehabilitation program that provided him with at least three
hours of therapy a day for at least 5 days a week. A formal team conference
was led by myself on a twice weekly basis to ensure a coordinated program of
care, as well as to maximize his functional recovery and minimize comorbidities.
Functionally, on admission the patient was minimal assist for cognition and
ADLs. By time of discharge he was supervision for feeding and grooming and
upper extremity dressing, and was able to perform toilet transfer and
tub/shower transfer with minimal assist to a bedside commode, as well as a
transfer tub bench. He was able to ambulate with a rolling walker up to 115 feet
via supervision and do four steps of stairs with minimal assist
Overall, as can be seen, Mr. Patient made excellent progress in his rehabilitation
program. He received education on his medical condition and medical
psychological support for abstinence regarding his substance abuse. He received
aggressive medical management regarding his multiple comorbidities to include
delirium tremens, congestive heart failure, pneumonia and hepatic insufficiency.
By xx/xx/xx (discharge date), he had made enough progress that we were able
to safely discharge him home in good condition. In summary, I do not feel that
Mr. Patient could have received the same type of intensive medical, nursing and
therapeutic care at any setting other than at Example Rehabilitation. He would
not have achieved the progress physically or medically in this short period of
time
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Medicare Appeal Decision
• Response to your appeal letter will be received within 60
days
• Billing department will either receives payment
electronically and/or there will be a written Medicare
Appeal Decision letter detailing the explanation of the
unfavorable decision or partial denial (partially
unfavorable)
 If not received within this time, the billing department
should contact the FI
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Step 3 - Reconsideration
• Next appeal level is an ‘on the record’ review by the QIC –
Qualified Independent Contractor
 Maximus in King of Prussia, Pennsylvania – East
Jurisdiction
• 26 states
• Washington , DC
• Puerto Rico, Virgin islands
 First Coast Service Options in Jacksonville, Florida –
West Jurisdiction
• 24 states
• Guam, Northern Mariana Islands, American Samoa
• Group of independent health professionals. If a physician
issue is involved, a physician will sit on the panel.
• This is meant to be an impartial review.
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Step 3 - Reconsideration
• FI forwards the medical record to the QIC. Sent with a
Reconsideration Case Summary Sheet on top of all
documents
 However, you should send the entire record again to the
QIC
• Tips:
• Appeal Decision may be several pages in length. Read
it entirely
• Request the materials the FI used to support their
decision
• Review additional Appeal Rights and respond on the
required form
• Respond promptly
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Step 3 - Reconsideration
• This is the last opportunity to submit new documentation to
support your claim. If any further documented evidence is
available but was not sent prior, submit it with this packet
 May want to consider obtaining a signed affidavit from
the patient as to their care, benefits from your care and
entitlement to the services
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Step 3 - Reconsideration
• QIC renders their decision within 60 days of receipt of
your Request for Reconsideration:
 Formal QIC decision is sent to the FI
 The FI now pays or takes the necessary action to issue
payment for the claim
• When the QIC decision is favorable:
 Amount to be paid is noted and the FI must pay within
30 days of the QIC’s decision
 Within 14 days of the date of payment the FI notifies
the QIC of the amount and date of the payment
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Step 3 - Reconsideration
• Medicare Reconsideration Decision will contain
information on your claim and further appeal rights
• Next level of appeals is an ‘on the record’ decision by an
Administrative Law Judge or a hearing by an
Administrative Law Judge
• The ALJ Hearing is initiated by preparing and sending the
forms to accompany the request for a hearing within 60
days
• Claim must be equal to or greater than $110 in
outstanding payments in order to be appealed at the ALJ
level
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Step 4 – Administrative Law Judge
• Facts about the ALJ:
 Managed by judges who are trained by HHS - the
Department of Health and Human Services
 Judges can decide cases without a hearing
 Hearing will either be in person, by telephone or via
video teleconferencing
 Hearing will be a taped, informal discussion of the
claim
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 Judge may be very knowledgeable or require
explanation of the claim
Step 4 - ALJ
• Send the medical record to the OMHA – Office of
Hearings and Appeals - even though the QIC will also
forward the record:
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Irvine, California
Cleveland, Ohio
Miami, Florida
Arlington, Virginia
You will be told in your QIC decision letter where to
send your request
Step 4 - ALJ
• Tips:
 Be well prepared
 Review the FI and QIC decisions
 Understand what you are defending
• Utilization, coding, duration of care
• Services provided
• Admission itself
 Organize the materials
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Step 4 - ALJ
• Judge will render his/ her decision within 90 days
• Additional appeal rights will be explained in the Administrative
Law Judge’s decision
• If the denial is overturned, the FI has 30 calendar days to pay
the claim from the date of the ALJ’s decision
• If the denial is not overturned, you may request a review by the
Department of Appeals Board also referred to as the MAC - the
Medicare Appeals Council -in Washington
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Step 5 – Medicare Appeals Council
• At this level of appeal you may group like claims together
into one claim.
 Submit medical records and DAB form to the MAC
 Submit explanation of your reason for an additional
review – Legal representation may be needed
 Submit within 60 days of receipt of the ALJ Decision
• MAC renders a decision within 90 days of receipt of the request
• If the decision is unfavorable, you may take the appeal to the
Federal District Court
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Step 6 – Federal District Court
• This is the final level of appeal
 All claims will be submitted as one case number
 You must file a request for a court appearance within
60 days of MAC decision
 The amount in dispute must be greater than $1130
 An attorney will lead this process and represent the
facility in court
 Staff members, former patients, and other facility
representatives may be encouraged to be witnesses
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Time Frames for Appeals
Level
Time Limit to File the
Request
Time Limit to Render the
Decision
Redetermination 120 days
60 days
Reconsideration
180 days
60 days
ALJ Hearing **
60 days
90 days
MAC Review
60 days
90 days
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Challenges
 Appeal all claims
 Track all claims
 Adhere to time frames
 Receive information from Business/Finance Office in a
timely manner
 Review carefully all documents from the FI
 Respond in a timely manner with the correct
documents
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 Be organized
Building Blocks
• Communication is critical among hospital departments such as:
• Billing Department or Chief Financial Officer
• Health Information Management
• Director of Nursing
• Chief Executive Officer or Administrator
 You need to appoint someone to manage the process.
Everyone should know where to send documentation
requests.
 Since the rehab unit knows how the patient was managed,
they should handle the appeal with input from the hospital
departments.
 All personnel involved in the management of health
information (records) and the finances of your organization
need to be informed of an ADR and progress made toward
resolving outstanding claims.
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Appeals Tracking
• What eRehabData tracks:
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Type of request
Dates of correspondence with the FI
Dates of responses from the FI
Reason for denial
Payment/denial amounts
• How we report it:
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Active appeals
Closed appeals
Total cases in appeal at each stage
Total dollars in dispute at each stage
Total dollars paid at each stage
Total dollars denied at each stage
Tracking Denials
• eRehabData is tracking referrals for 3 reasons
 For you to effectively manage your denials
 To be able to share information among subscribers
about what is outstanding in claims, trends in denials,
and tricks of the trade for the appeals process
 To provide definitive information to CMS about the
activity of its contractors
• In order to do this, we need your help
 Take advantage of the system
 Keep the information up to date
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Questions?
For a soft copy of these slides,
please email me:
[email protected]
(202) 588-1766