Medicare Compliance & Reimbursement

5 tips for mastering notification requirements.

New fast-track appeals requirements are catching most comprehensive outpatient rehab facilities by surprise, and it's a nasty surprise indeed.

As required by a settlement in the Grijalva v. Shalala lawsuit, the Centers for Medicare & Medicaid Services began requiring new notices of termination of coverage for Medicare+Choice enrollees Jan. 1 to facilitate speedy appeals decisions. And the requirements for the fast-track appeals process are translating into extra costs and headaches for CORFs that contract with the Medicare managed care plans.

In addition to the termination of coverage notice, CORFs (along with skilled nursing facilities and home health agencies) also must furnish documentation supporting the termination decision to the independent review entity (IRE) - generally a quality improvement organization (QIO) - in time for the decision deadline of four days from the initial notice.

"It seems like an anomaly to include CORFs with SNFs and HHAs in these requirements" notes Cherilyn G. Murer, president and CEO of Murer Consultants Inc. in Joliet, IL. That's because CORFs' coverage windows are based on medical necessity, not on structured timetables like SNFs and HHAs, she explains.

Nonetheless, CORFs are included and must comply with the new rules.

Get ahead of the pack: The Grijalva requirements have caught many CORFs unaware, says Burtonsville, MD-based attorney Elizabeth Hogue. And unfortunately, many "are going to get bitten first, before they wise up," she says.

This bite will come from the Medicare+Choice organization itself - and it's likely to be biting in anger. That's because if CORFs fail to deliver the notice at least two days before discharge, the M+CO is on the hook for coverage of the services until the notice is delivered and the fast-track appeals process timeline starts.

What to expect: To keep CORFs in line with the requirement, CMS has given M+COs freedom to penalize providers however they see fit. That will likely translate into things like withheld payments and terminated relationships - "scary stuff," according to Hogue. "They're shifting the burden of compliance to providers," she says.

In fact, CMS repeatedly has told plans and providers that it won't referee between them on the details of the notice-delivery system. Plans and providers must work out those details themselves in their contracting agreements. Ramifications for noncompliance "will be a work in progress," predicts Murer.

"Accomplishing proper advance notice of termination by the provider is going to require coordination and information-sharing between those entities to make sure that enrollees get the right information at the right time," a CMS staffer stressed in a recent open door forum on the matter.

Opening up those lines of communication could be one very positive result of these requirements, opines Ken Mailly with Mailly & Inglett Consulting in Wayne, NJ. But "a lot more than communication" between plans and providers will be needed to nail down the details, insists Linda Cioffi, vice president of care management with Touchstone Health Partnership, Inc. in New York City.

Avoid this pitfall: CORFs that do little or no managed care business may be tempted to ignore the Grijalva regulations, but that could be a very bad idea. Similar fast-track appeal requirements for regular Medicare beneficiaries are in the works, CMS said in the open door forum.

5 Steps For Success

To steer clear of trouble with the new managed care appeals burden, CORFs should consult these five pointers, which CMS offered in the open door forum.

1. Don't treat Grijalva notices like ABNs. It doesn't matter if the physician, patient and managed care plan all agree that the services are no longer medically necessary, CMS hammered home in the forum. Any time M+CO-covered services are terminated, even if it's in accordance with the original plan of treatment, CORFs must issue the initial notice telling managed care enrollees the date and time their coverage will end.

2. Skip eval notices. Initial notices are not required if the CORF conducts a one-time evaluation, such as an assessment for physical therapy or for home safety, CMS officials explained at the forum.

3. Stay up to date. Providers wanting to protect themselves from financial liability for non-covered care should use the most recent forms for the Grijalva notice, CMS said. They are available at www.cms.hhs.gov/healthplans/appeals/.

CORFs should be on the look-out for updated forms in the near future. CMS continues to take comments on the notices, particularly the initial Notice of Medicare Non-Coverage (NOMNC), and plans some significant changes.

4. Obtain signatures. It is the CORF's responsibility to obtain a signature proving it delivered the NOMNC. And it's not just a matter of giving the patient notice, counsels Murer. The CORF also is responsible for ensuring that the patient fully understands what the notice means, she emphasizes. "There needs to be an attestation of understanding."

5. Keep a copy. A copy of the signed notice should become part of the patient's medical record, CMS says in a set of frequently asked questions posted to its appeals Web site.

Editor's Note: Send questions about Grijalva appeals to Grijalva/NODMARQuestions@cms.hhs.gov. Submitters may receive individual responses or see answers posted at www.cms.hhs.gov/healthplans/appeals/FAQs12-17.pdf.