Home Health & Hospice Week

CMS reveals details on revamped appeals process set to hit next month.

The new rule limiting Medicare appeals evidence submission to the reconsideration level might not be as hard and fast as you think.

So indicated Centers for Medicare & Medicaid Services officials in an April 15 special Open Door Forum on the overhauled Medicare claims appeals process. The forum drew more than 800 callers. The new appeals procedures will take effect for home health agencies and hospices May 1 and durable medical equipment suppliers Jan. 1, 2006.

CMS published in the March 8 Federal Register an interim final rule on the appeals changes, which were mandated in the Benefits Improvement and Protection Act of 2000 and the Medicare Modernization Act of 2003 (see Eli's HCW, Vol. XIV, No. 10).

One of the most onerous new provisions is the requirement for "full and early submission of evidence." Under the new rule, providers must submit any and all evidence by the second level of appeals, conducted by the new qualified independent contractor (QIC). In contrast, CMS can participate in or enter a hearing as a party at the administrative law judge (ALJ) or Medicare Appeals Council (MAC) level and submit new evidence at that time.

Play fair: Critics have said this provision will make winning appeals more difficult for providers.

But under the new requirement, providers can submit evidence later if they have good cause, CMS officials pointed out in the forum. And a very good reason for submitting later evidence could be responding to evidence that CMS has presented. Another good reason would be responding to information that came to light from the QIC decision, CMS added.

"That whole provision was intended to stop venue-shopping and situations where people had documentation, but chose not to submit it until the higher level," said Tony Culotta, director of CMS' enrollment and appeals division.

Anyway, providers shouldn't expect CMS to intervene in many cases, one CMS official said. Due to resource limitations, CMS plans to invoke party status only for "large dollar cases" or "very important policy issues," she said in the forum.

Lack of Reopening Deadline Causes Concern

Providers remain confused about what will count as a technical error in the future. Under the new rule, technical errors can be corrected with reopenings rather than full-blown reconsiderations.

CMS has instructed intermediaries and carriers to process technical errors as reopenings, and "hopefully there won't be too many disagreements about what's a clerical error and what's not," CMS' Jennifer Collins noted in the forum.CMS promised to issue guidance to contractors on what constitutes technical errors, and told providers to expect educational efforts on the subject from their intermediaries or carriers.

Because CMS neglected to include a deadline for reopening decisions in the rule, providers may find they are out of time to file an appeal if their intermediary rejects the reopening, Andrew Koski of the Home Care Association of New York State noted in the forum.

CMS said it would likely issue a reopening decision deadline in less formal guidance, such as a manual instruction.

Other facts revealed in the forum include: