Medicare Compliance & Reimbursement

Long-delayed coverage appeal rule at last in final form. 

Burdensome physician certification rules that could have derailed beneficiary appeals of Medicare coverage decisions have been stripped from the books.

In a final rule governing beneficiary appeals of national and local coverage determinations, the Centers for Medicare & Medicaid Services relented on stringent certification requirements contained in its Aug. 22, 2002 proposal. Those requirements have been relaxed in the final rule: Now, certification that a service is necessary can simply be in the form of a written order or another component of the medical record. In addition, physicians won't be required to predict that payment would be denied.

Under the rule, published in the Nov. 7 Federal Register, appeals of local coverage determinations would be reviewed by administrative law judges. Appeals of national coverage determinations, and of ALJ rulings on LCDs, would be heard by the Health and Human Services Departmental Appeals Board. DAB decisions could then be appealed in federal court.

The rule goes into effect Dec. 8, 2003.

To see the rule, go to www.access.gpo.gov/su_docs/fedreg/a031107c.html.

Lesson Learned: CMS' new appeals rules should make it easier for Medicare beneficiaries to appeal - and perhaps reverse - decisions that rule out coverage for certain services.