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Appeals:

Know Your Facts: Medicare Claims Appeals Changes

Published on Thu Feb 10, 2005

ALJs' move to HHS tops lengthy list of Medicare appeals reforms taking place soon.

Medicare appeals changes will soon be upon you, and you'd better be aware of the differences or miss out on your chance to effectively pursue payment for incorrectly denied claims.

The Centers for Medicare & Medicaid Services is getting ready to implement a host of appeals changes required by the Benefits Improvement and Protection Act of 2000 and the Medicare Modernization Act of 2003, according to a final interim rule published in the March 8 Federal Register. Here are some of the most important changes you'll see:
 

  • QICs. CMS will implement a contractor for second-level appeals, the qualified independent contractor (see Eli's HCW, Vol. XIII, No. 36). For Part A providers including home health agencies and hospices, this will be a whole new level of appeals. For Part B providers including durable medical equipment suppliers, QICs will replace fair hearing officers at the DME regional carrier.

    QICs will start reviewing Part A claims in May and Part B claims next January, CMS says. QIC reviews will be "on the record" reviews rather than in-person hearings.
     
  • Timelines. The aim of most of the changes, including new deadlines for each level of appeal, is to make the Medicare appeals process quicker and more efficient. Providers have 180 days to file a request for redetermination on a claim, then their intermediary or carrier has 60 days to make the redetermination. Next, providers have 180 days to request a reconsideration from the new QICs, and the QICs have 60 days to complete them. Providers then have 60 days to request an administrative law judge review, and the ALJs have 90 days to issue their decisions. Finally, providers have 60 days to file an appeal with the HHS Departmental Appeals Board Medicare Appeals Council, and the MAC must issue its decision within 90 days. After that, providers can pursue the appeal at the federal court level within 60 days.
     
  • ALJs. By October, the ALJs will move from the Social Security Administration to the Department of Health and Human Services. Both the QICs and the ALJs must give "substantial deference" to CMS program guidance, the agency says in the notice.
     
  • Full and early presentation of evidence. When the QICs take effect, providers must submit any and all evidence for an appeal no later than during the QIC reconsideration.
     
  • Direct appeal rights. "Providers may file administrative appeals of initial determinations to the same extent as beneficiaries," CMS says. This is a change for Part A providers.
     
  • New redetermination notices. When carriers or intermediaries review your claims and uphold part or all of the denial or downcode, they must issue new redetermination notices that specify necessary missing documentation.
     
  • CMS and contractor involvement. CMS will be able to submit evidence at the ALJ level even though providers won't be allowed to. And CMS and its contractors can be a party to the ALJ hearing, meaning they can call and cross-examine witnesses, etc. 

    Source: Interim final rule, March 8 Federal Register,     www.access.gpo.gov/su_docs/fedreg/a050308c.html.

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