Home Health & Hospice Week

 Rule changes could damage your chances of a successful appeal, experts fear.

Under the new appeals system, adjudicators don't want to see your face much - and that's probably not good for your case.
 
The Centers for Medicare & Medicaid Services has set out a new appeals system featuring the qualified independent contractors (QICs) and speedy new timelines for decisions (see Eli's HCW, Vol. XIV, No. 10, p. 74). The system took effect for home health agencies and hospices last month and goes into place for durable medical equipment suppliers Jan. 1, 2006.
 
The new system reduces providers' chance of putting their case in front of a live adjudicator, legal experts note. For example, the second level of appeals for suppliers is the fair hearing officer and the hearing can be conducted in person. But starting in January, the QIC will take over the second level of appeals and will conduct on-the-record reviews only.
 
And most administrative law judge hearings currently are conducted in person. But under the new system, when the ALJs switch over to the Department of Health and Human Services, teleconference hearings will become the norm. Providers will have to waive their right to a 90-day decision if they wish to conduct an in-person ALJ hearing.
 
The ALJ change is partially due to the fact that HHS plans only three field offices and a headquarters for the whole nation (see Eli's HCW, Vol. XIV, No. 14, p. 111). Prominent lawmakers have challenged the move, but cost concerns are likely to trump ethical objections about in-person versus video hearings, experts predict.

Providers' Hands Tied in On-The-Record Hearings

Providers will face their first challenge in the on-the-record hearing at the QIC, says attorney Denise Fletcher with Brown & Fortunato in Amarillo, TX. "When it's all on the record, it's a lot harder to get ideas across," Fletcher tells Eli.
 
For example, providers can't point to a certain line on a claim or in a policy, Fletcher protests. And suppliers fear QIC reviewers will fail to take the time to read physician progress notes carefully.
 
You can't have live witnesses testifying on your behalf at the QIC, points out attorney Lester Perling with Broad and Cassel in Ft. Lauderdale, FL. You lose out on the credibility an in-person explanation can bring to the matter.
 
In Perling's estimation, video conferencing for ALJ hearings isn't much of an improvement over on-the-record reviews. "It's hard to have personal interaction" in a video conference, he criticizes. "Maybe I'm old-fashioned," but video conferences just don't work as well as in-person hearings, he says.
 
People speak over each other and generally miss information. And if you have a complicated case with a lot of documents to reference, the judge is likely to get confused and overlook the information you could have pointed out in person, Perling fears.
 
Despite the financial drawbacks, Perling may recommend that his clients waive the faster timeline to secure an in-person ALJ hearing if they have a complicated case, he says. If  a case is simple and doesn't involve a lot of documents or witnesses, a video conference "may be OK," he predicts.