Medicare Compliance & Reimbursement

In addition to requiring a standardized explanation of benefits (EOB) and allowing the provider to become a claimant, the final PPACA regulations also set forth the following new requirements of which your practice should be aware:

• Clarification of the meaning of adverse benefit determination -- this means that rescission of coverage is considered a denial and patients can use the entire ERISA appeals process to fight the denial/policy cancellation.
• Expedited urgent care determination -- this regulation stated that insurance companies had to determine benefits involving urgent care within 24 hours. This requirement was "cancelled," Zhou explains. "The urgent care decision making now has to be as soon as possible, and goes back to the original ERISA regulation which is 72 hours," he adds.
• Full and fair review -- "The new regulation says that if you ever introduce new evidence (such as a pathology report that wasn't looked at before) or you employ a new rationale, you must make advance disclosure," Zhou explains. "That means the plan must tell the claimant far in advance so there's time to understand and appeal the new rationale or evidence."
• Avoid conflict of interest -- this means insurance companies can't use someone to do appeals that has a conflict of interest. For example, if Person A does the first level of appeal and Person B does the second level of appeals, but Person A is Person B's boss, that would be a conflict of interest, Zhou says.
• Code definitions on EOBs -- this regulation said that insurance companies had to put the ICD-9, CPT®, and HCPCS code definition on the EOB. "We knew this would not fly under HIPAA," Zhou laments. The regulation was eliminated as well. The codes will appear, but not the definitions.