Appeals:
Plan Ahead To Dodge Expedited Review Disaster
Published on Fri Dec 17, 2004
Avoid Friday and Saturday notice deliveries for questionable cases. Warning: Your requirements under new termination notice and expedited review rules could hang you if you don't know the ropes.
The Centers for Medicare & Medicaid Services will require home health agencies to deliver a termination notice every time a beneficiary's Medicare services come to an end, the agency said in the Nov. 26 Federal Register (see Eli's HCW, Vol. XIII, No. 43, p. 338). Then beneficiaries can appeal the termination, receiving a decision under an expedited 72-hour timeframe.
The deadlines under expedited review, which will start in July, will be tight, notes consultant Judy Adams with the LarsonAllen Health Care Group in Charlotte, NC. That will leave HHAs no room for error.
When a beneficiary elects expedited review, the Quality Improvement Organization contacts the agency the day after it issues the first-step, generic termination notice.
Once contacted by the QIO, the HHA must issue a second, more detailed notice to the beneficiary explaining the reason for termination by the end of the day, CMS spells out in the final rule. And the agency must forward all relevant records to the QIO that day as well. Industry Protests Timeline That timeline has the industry up in arms. "The one-day turnaround ... does not appear to be practical or workable," criticizes Ann Howard with the American Association for Homecare. The timeframe may be "impossible" for some agencies to meet, Howard insists.
"The turnaround time to submit all of the relevant documentation to the QIO ... seems unrealistic and needs to be revised," charges Patrick Conole with the Home Care Association of New York State.
A same-day turnaround simply doesn't give agencies sufficient time to respond, agrees Mary St. Pierre with the National Association for Home Care & Hospice.
And if agencies can't meet the timelines, the punishment will hit them square in the wallet. The QIO can delay the decision until it receives the agency's documentation - and the agency has to continue and pay for services for that period. That will be a financial burden, notes consultant Pat Sevast with American Express Tax & Business Services in Timonium, MD.
Or the QIO may overrule the agency's termination decision, CMS indicates. That could put the HHA on the financial hook if the intermediary later denies the claim. Beware Weekend Notices Generating and delivering a detailed notice and sending records to the QIO all during one day will be hard enough during the week, St. Pierre points out. If the QIO's message about the expedited review goes astray - into an absent worker's voice mail box, for example - the timeline is shot, Sevast notes.
And having to deliver a same-day detailed notice will almost certainly mean an extra, non-covered [...]
