Home Health & Hospice Week

Providers will receive time-saving direct appeals rights.

The Centers for Medicare & Medicaid Services is implementing sweeping appeals changes, and direct appeal rights is one reform that should make providers' lives easier.

CMS will start putting the wide slate of appeals changes into effect this summer, it says in an interim final rule published in the March 8 Federal Register (see Eli's HCW, Vol. XIV, No. 10).

Home health agencies are greatly looking forward to the provision that will grant them the same appeal rights as beneficiaries. "With this, HHAs and others will no longer have to deal with the nightmare of getting Appointment of Representative forms signed by beneficiaries," cheers William Dombi with the National Association for Home Care & Hospice.

Warning: But providers may not always want to elect direct appeal rights, advises Jin Zhou, president of ErisaClaim.com.

The regulation forces providers to choose between two different roles in an appeal: You can be the beneficiary's "appointed representative" or "authorized representative."

If you're appointed, you need to obtain the patient's specific approval for each item you appeal. If you're authorized, you have the same rights as the beneficiary where appeals are concerned. But if you don't appeal "diligently" and then lose, you won't be able to collect any money from the beneficiary, Zhou says.

Plan of action: If you suspect services may not be payable, you should appeal as the appointed beneficiary so you can bill the patient afterward. But if you know the patient won't be able to pay at all, go ahead and appeal as the authorized beneficiary, Zhou counsels. Medicare will have standard forms to let you sign up as either type of representative.

Claims Pile-Up Expected On Appeals Highway

The aim of the appeals overhaul, including new deadlines, is to process claims appeals more quickly and efficiently, CMS says. But don't expect your appeals to go faster any time soon.

"In the short term ... we recognize that implementing the changes set forth in this interim final rule may prove challenging both for the entities responsible for conducting appeals and for appellants themselves," CMS cautions.

More providers might want to take advantage of the new QIC process, hoping for a more fair review of their claim. And more providers may decide to proceed to the administrative law judge and Medicare Appeals Council levels because timeframes for receiving decisions will become considerably shorter.

The appeals entities will also be running parallel procedures for appeals filed under the new rules versus the old ones. All that is likely to mean a glut of appeals that will take a while to work through, CMS warns.

Appeals for suppliers may be slower, too, because they will have to submit all reconsideration requests in writing under the new process. Currently, they often can request a reconsideration over the phone, CMS says in the rule.

Guinea pigs: The new QICs will start accepting appeals for Part A providers including HHAs and hospices in May and Part B providers including durable medical equipment suppliers next January. Because CMS expects the Part A appeals load to be much smaller than the Part B one (which includes physician claims), adopting Part A appeals changes first will give the appeals officials a chance to "troubleshoot" the problems before taking on the main workload. 

Editor's Note: The interim final rule is at www.access.gpo.gov/su_docs/fedreg/a050308c.html.