Medicare Compliance & Reimbursement

Providers that don't learn new rules early could be sorry all next year.

Starting this January, having your ducks in a row will be more important than ever for providers when it comes to submitting appeals for denied claims.

When the Centers for Medicare and Medicaid Services' new appeals process kicks in, providers only have one chance to get appeals right.

If a provider doesn't include all the important information in its second-level appeal to the Qualified Independent Contractor, then the provider won't be able to add any more information except if there is "good cause." Also, the timeframe to submit QIC appeals will shorten from six months to 180 days as of next January. 
  
And the Administrative Law Judges who consider appeals after the QIC level will be Medicare specialists, instead of Social Security ALJs on loan.

Be prepared: So "you have to have your case better organized," says attorney Alice Gosfield at Gosfield & Associates in Philadelphia.
 
Providers will also have to make sure appeals have complete documentation the first time around, including pictures and all substantiating evidence, says Barbara Cobuzzi, president of Cash Flow Solutions in Cherry Hill, NJ.

Idea: Set up better processes to manage appeals, so that every appeal runs more smoothly, Cobuzzi adds.  Compile a checklist of sources to assist in assembling documentation for every appeal - and also substantiating sources like the CPT Assistant and Medicare Carrier's Manual to check in every case.

Do The Research At The Start

With the new CMS appeals process on the horizon, "up-front research is really important now," says Tammy Tipton, president of Appeal Solutions in Blanchard, OK. "You really don't have time to gather information before you move on; you really have to do it before the [carrier-level] reconsideration."

Providers should have dedicated staff who work on appeals, says Tipton. Ideally, at least one person's time should be devoted entirely to appeals.
 
Also, a provider may want to invest in "appeal management technology," such as software that helps you track your denials so it knows how much time has elapsed since the denial.

Providers have been asking CMS to speed up the appeals process for a long time, so they can't really complain about shortened timeframes, says attorney Michael Manthei with Holland & Knight in Boston.
 
"Overall for providers, it will be much better if [an appeal] goes quickly, even if it puts more of a burden on a provider to get his records together," Manthei notes.