Home Health & Hospice Week

Good cause for post-QIC submission of evidence may be trickier than CMS indicates.

The new requirement for full and early presentation of evidence is going to be a major burden on providers' Medicare appeals - and it will be even worse if you think loopholes in the rule will be easy to negotiate.

In a recent Open Door Forum on the appeals process changes, Centers for Medicare & Medicaid Services officials indicated submitting evidence after the qualified independent contractor (second) level of appeal would be pretty simple, despite the rule. Providers would have to show good cause for the later submission, and a host of reasons would qualify as good cause, CMS said.

Not so fast: But observers aren't so sure that really will be the case. Andrew Koski of the Home Care Association of New York State has "concerns about providers not being able to submit evidence after the QIC stage," he tells Eli. "CMS gave the impression that it will be easy to submit new evidence at later stages, when the regulations restrict such submissions."

"Don't rely on the information from the Open Door Forum," cautions attorney Mary Beth Gettins with Covington, KY-based Pearson & Bernard. "This is a strong area of concern." Find Out What the Change Means for You As part of the appeals overhaul which takes effect May 1 for Part A and Jan. 1 for Part B, providers now must comply with full and early presentation of evidence - that means they must submit all evidence by the reconsideration (second) level at the QIC. The problem is that providers have 180 days to request a redetermination (first-level appeal) from their intermediary or carrier, then 180 days to request a reconsideration from the QIC.

Chasing down progress notes from physicians takes durable medical equipment suppliers a long time, relates attorney Denise Fletcher with Brown & Fortunato in Amarillo, TX. The timeline for the first two levels of appeal often won't be long enough to track down documentation, Fletcher worries.

"The timeframes for producing medical records evidence ... throughout this rule are unrealistic in the context of a non-institutional benefit," criticizes Bob Wardwell with the Visiting Nurse Associations of America. "It's not like the patient's record is on the second floor nurses station, the patient is across the hall and the missing patient note is down the hall in the PT department," notes Wardwell, a former top CMS official.

Having providers submit much more detail, including evidence, early in their appeals will translate to "more substantial expenditures of time and resources (including legal fees) at earlier stages of the process," warns attorney Joel Hamme with Powers Pyles Sutter & Verville in Washington, DC.

And providers likely will have a tough time figuring out exactly [...]