Appeals:
HHAs MUST TAKE ON MANAGED CARE APPEALS BURDEN
Published on Sun Jun 01, 2003
If you contract with Medicare managed care organizations, brace yourself for a whole new level of paperwork, thanks to changes to the patient appeals process. And all Medicare home care providers should heed the new procedures as a harbinger of appeals changes to come in the regular Medicare fee-for-service world. Starting in January 2004, the Centers for Medicare & Medicaid Services will require two-step notices of termination of services for Medicare+Choice patients receiving care from home health agencies, nursing homes or certified outpatient rehab facilities, CMS outlines in an April 4 Federal Register notice. Home health agencies will be responsible for generating and delivering at least the first notice.
"MCO appeal rights ... should be on the home care radar screen," urges William Dombi, vice president for law with the National Association for Home Care & Hospice's Center for Health Care Law. CMS' proposed appeals regulations "implicate the HHAs directly and indirectly," Dombi says. Every time an M+C organization decides to discontinue home care services to an enrollee, the HHA must issue a "generic" notice to that patient, according to the final reg with comment. CMS will craft the generic notice template, which will inform enrollees of their appeal rights, and obtain Office of Management and Budget approval for the form. HHAs must insert the patient's name and the date the services will terminate onto the form, then deliver the form to the patient as late as the next-to-last visit or at least two days before the termination of services is scheduled. Agencies must have patients sign and date the notice to acknowledge they have received and comprehended it. That's where agencies' responsibilities end under the reg. But that responsibility will be burdensome enough, predicts attorney Jeffrey Schneider with Hogan & Hartson in New York. HHAs often won't know by the next-to-last visit whether the M+CO will terminate the patient's services, Schneider tells Eli. That means when the decision does come down, agencies will have to make an extra visit solely to deliver the first, generic notice. That translates to extra costs and overhead. "It will be a particular challenge for agencies to deliver notices promptly," especially compared to nursing homes and CORFs, predicts Bob Wardwell with the Visiting Nurse Associations of America. CMS appears to assume that HHAs furnish patient visits at regular intervals, when time between visits actually can vary drastically, notes Wardwell, a former CMS official. With no knowledge of service termination ahead of time, "the home health nurse will have to jump in the car, drive out and deliver the bad news," when the M+CO makes the call on discontinuing services, Wardwell laments.
"It's not just going down the hall," as it will be for institutional [...]
