Home Health & Hospice Week

If you do any business with Medicare managed care providers, you'd better get to know your new appeals obligations on the double. Many of the requirements will be regulatory, meaning you could see survey deficiencies if you fail to comply with them.

Under the final rule on Medicare+Choice appeals procedures published in the April 4 Federal Register, the Centers for Medicare & Medicaid Services says home health agencies must:

1) Furnish a notice to M+C organization enrollees when the health plan decides to terminate their services. The notice must include the date coverage of services ends; the date the enrollee's financial liability for continued services begins, a description of the enrollee's right to a fast-track appeal; and the enrollee's right to a more detailed notice of why the M+CO is terminating services.

CMS will provide a template for the notice, so HHAs will have to insert only the patient's name and the date services will end.

2) Deliver the notice to the patient no later than the next-to-last visit before termination, or two days before termination. The HHA must obtain the patient's signature and date on the notice, verifying the patient received and comprehended it.

3) Furnish documentation to the M+CO or independent review entity to help adjudicate the appeal. The IRE will have four days from the initial notice to make a decision.

Home care providers may wish to negotiate with their M+COs on whether they will take on extra responsibilities related to generating and delivering the second, more detailed notices explaining why the health plan terminated services. The regulation places responsibility for those notices squarely on M+COs shoulders, but health plans may delegate those duties to providers if they wish, notes American Association of Health Plans spokesperson Mohit Ghose. Consequences for the notices, such as continued coverage for services when notices aren't delivered, still would lie with the M+CO, CMS specifies in the reg.