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Medicare Compliance & Reimbursement

REIMBURSEMENT:

Get Up To Speed On CMS' Improved Appeals Procedures

Published on Mon Jan 03, 2005

Surprise: New changes could actually make life easier for providers

Getting in the loop on revisions to the Medicare claims appeals process is relatively painless - and could help save time and money.

Provisions in the Medicare Modernization Act (42 U.S.C. 1395ff) include changes to the appeals process that contractors need to be implementing, says Steve Verno, CMBSI, NREMPT, a practice manager with Emergency Medicine Specialists and former compliance director for the Medical Association of Billers. Verno recently gave a teleconference on Medicare's updated appeals process for the Coding Institute and Eli Research.

Watch out for these Medicare changes and improvements:

Expedited access to judicial review (section 931): In certain appeals of part A or part B claims, providers can have expedited review when the Departmental Appeals Board lacks authority to decide a question of law or regulation.

Presentation of evidence: As of Oct. 1, 2004, providers can introduce new evidence during appeal to the Administrative Law Judge if good cause is shown. "There could be a thousand different reasons" to justify a claim, says Verno. The reasons include a sudden, relevant change to a local Medicare review policy or National Correct Coding Initiative edit.

Denials (section 933): Notices of initial and re-determinations, reconsiderations and the Administrative Law Judge's decisions will contain key information. Examples include whether a local medical review policy was used, the procedures for getting more information and instructions on how to initiate an appeal, Verno says. Important: In cases where medical necessity is involved, Medicare must include "a summary of the clinical or scientific evidence it used," he says.

Corrected claims (section 937): Correct minor errors - such as a missing modifier - without filing an appeal. How: Simply resubmit the corrected claim and Medicare will no longer deny it as a duplicate, Verno says.

Jurisdictional amount: The minimum amount of the claim providers can present before an administrative law judge is going to increase each year. Tip: Start looking at monthly Medicare notices to find the amount required, Verno says.

Prior determination (section 938): Find out whether the contractor covers a procedure or service before you ever perform it. After answering an inquiry, a contractor has 45 days to inform the beneficiary of its decision. Key: "The determination that the service is covered is binding on the contractor, so the onus is on the vendor itself," Verno adds.

To obtain a CD or print transcript of "5 Steps to Successful Medicare Appeals," go to www.codinginstitute.com or call 1-800-508-2582.

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