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Home Health & Hospice Week

Appeals:

Examine Your New Duties Under Expedited Review

Published on Thu Dec 09, 2004

You'll have less than a day to turn around review records.

Home health agencies and hospices are in for a whole new level of burden under expedited appeals rules.
 
Here's the rundown of what the Centers for Medicare & Medicaid Services will require when beneficiaries want to appeal Medicare service terminations:

What you do: Furnish a valid initial notice when the beneficiary's Medicare services are scheduled to end. Providers must deliver the notice at least two days before the termination, or on the next-to-last visit, and secure the beneficiary's signature verifying her receipt of it.
 
Notices aren't required when the HHA merely reduces services, CMS notes in its final rule published in the Nov. 26 Federal Register.

What the beneficiary does: If she disagrees with the termination and wants an expedited review, a beneficiary first must obtain a certification from her doctor stating the termination will put her health at "significant risk." Hospice patients require no such certification.
 
Then, to qualify for the 72-hour expedited review timeframe, the beneficiary must request such a review from the Quality Improvement Organization by noon on the day after the agency delivered the initial notice. The request can be made by phone or in writing.

What the QIO does: The QIO then notifies you of the expedited review.

What you do: After being notified of the review, you must furnish by the end of that day a second, more detailed notice to the beneficiary explaining the termination. The detailed notice must include:

 

  • a specific explanation of why services are no longer reasonable and necessary or are no longer covered;
     
  • a description of any applicable Medicare coverage rule, instruction or policy, including citations to the information or details about how the beneficiary may obtain a copy of materials; and
     
  • facts explaining how the rules apply to the beneficiary's case.
     
    You also must furnish copies of the notices and supporting records to the QIO for review that same day. And CMS requires you to furnish copies of what you send to the QIO to the bene by the following day.

    What the QIO does: The QIO examines the records and information you furnish and questions the beneficiary, if necessary. The organization then issues a determination within 72 hours of receiving the beneficiary's review request.

    What the beneficiary does: If the beneficiary disagrees with the review decision, she then can request an expedited reconsideration of the decision.

    What the QIC does: A Qualified Independent Contractor conducts the reconsideration along similar timelines. The QIO forwards its documentation on the case, and you furnish additional information only if you want to, CMS spells out in the rule.

    What you do: You can bill for services provided after the termination date once the QIO or the QIC upholds your termination decision.

    What the beneficiary does: The beneficiary can appeal the QIC decision to the Administrative Law Judge under normal timelines, if she chooses.  

    Editor's Note: The final rule is at     www.access.gpo.gov/su_docs/fedreg/a041126c.html.

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