Medicare Compliance & Reimbursement

Strict new protocols highlight alterations.

If you're a provider who has gotten used to flexibility in the appeals process, get ready to tighten your belt. CMS will soon put into play its Medicare claims reforms- and recouping pay for improper claim denials isn't going to be as simple as it used to be.

The Centers for Medicare and Medicaid Services is about to implement a host of appeals required by the Benefits Improvement and Protection Act of 2000 and the Medicare Modernization Act of 2003, according to a final interim rule in the March 8 Federal Register.
 
Here's What to Expect CMS will implement a contractor, the qualified independent contractor, for second-level appeals. QICs will start reviewing Part A claims in May and Part B claims next January, CMS says.
 
For Part A providers, including acute inpatient and IRFs, this will be a whole new level of appeals. For Part B providers, including outpatient rehab providers and private therapy practices, QICs will replace fair hearing officers at the regional carrier.

"Now, for evidence to be considered at the ALJ level," your evidence first must be reviewed by QICs, explains attorney David Glaser with Fredrikson & Byron in Minneapolis.

Part B therapy providers may have more adapting to do than the Part A group. Beef Up Documentation to Ensure Appeals Success
 
The QIC process will be based on written evidence only, much like the current Part A review process, says attorney Lester Perling with Broad and Cassel in Ft. Lauderdale, FL. "The change may actually be greater for Part B providers because they are used to a fair hearing," he says.

Trap: Don't rely solely on the chart to tell the whole story. "It's likely that reviewers will be looking for clinical vignettes," says attorney Rob Wanerman with Epstein Becker & Green in Washington, DC. So include a document in your records that spells out why a particular patient needed a certain modality or plan of care. A reviewer might say, "under those circumstances I might not have done it that way, but what you did seems reasonable, and you certainly did provide appropriate care," offers Wanerman.

Timelines: The aim of most of the changes, including new deadlines for each appeal level, is to make the Medicare appeals process quicker and more efficient. Under the new appeals process:   Providers have 180 days to file a request for redetermination on a claim; then their intermediary or carrier has 60 days to make a decision on whether or not to approve the request.
   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 [...]