Home Health & Hospice Week

Consult these five pointers on the new managed care appeals burden.

Think the new Medicare managed care appeals process is the responsibility of Medicare+Choice Organizations instead of you? Think again.

Home health agencies have significant duties mandated under the regulations that require a new fast-track appeals process for M+CO enrollees (see HCW, Vol. XIII, No. 4).

Due to some ambiguities in the regulations, it may be months before HHAs can master the basics of the Grijalva appeals process for the M+CO program, now known as Medicare Advantage. But HHAs can start out by reviewing these pointers the Centers for Medicare & Medicaid Services offered in a Jan. 22 Open Door Forum on the issue:

1. Don't treat Grijalva notices like ABNs. It doesn't matter if the physician, patient and managed care plan all agree that the services are no longer medically necessary, CMS hammered home in the forum. Any time M+CO-covered services are terminated, even if it's in accordance with the original plan of treatment, HHAs must issue the initial notice telling managed care enrollees the date and time their coverage will end.

On the other hand, agencies don't have to deliver the notice when services are merely reduced - another difference from the advance beneficiary notice process.

2. Skip eval notices. Initial notices are not required if the agency conducts a one-time evaluation, such as an assessment for physical therapy or for home safety, CMS officials said in the forum.

3. Stay up to date. Providers wanting to protect themselves from financial liability for non-covered care should use the most recent forms for the Grijalva notice, CMS said. They are available at www.cms.hhs.gov/healthplans/appeals/.

Be on the look-out for updated forms in the near future. CMS continues to take comments on the notices, particularly the initial Notice of Medicare Non-Coverage (NOMNC), and plans some significant changes.

4. Obtain signatures. It is the HHA's responsibility to obtain a signature proving it delivered the NOMNC. In response to a forum question from the American Association for Homecare's Ann Howard, a CMS official said the signature doesn't have to be obtained in person. For example, it can be collected via fax. But generally, HHAs should follow ABN guidelines on the signature requirement, the CMS staffer instructed.