Optometry Coding & Billing Alert

In 9 months, you'll have less time for CMS appeals - is your practice ready?

Good optometry practices place a high value on organization. Starting January 2006, having your ducks in a row will be more important than ever before when it comes to submitting appeals for denied claims.

When CMS' new appeals process kicks in, you'll only have one chance to get your appeals right. If you don't include all the important information in your second-level appeal to the qualified independent contractor (QIC), then you won't be able to add any more information unless there is "good cause."

Expect Only 6 Months for QIC Appeals

Also, the time frame to submit your QIC appeal will shorten to 180 days as of next January. And the administrative law judges (ALJs) who consider appeals after the QIC level will be Medicare specialists, instead of Social Security ALJs on loan.

So "you have to have your case better organized," says attorney Alice Gosfield at Gosfield & Associates in Philadelphia. "You're going to have to be much more on top of what you're doing."

You'll have to make sure your appeals have complete documentation the first time around, including pictures and all substantiating evidence, says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions in Cherry Hill, N.J.
 
Idea: You may have to set up better processes to manage appeals so that every appeal runs more smoothly, Cobuzzi adds. "When you've got reliable processes, that's how you make sure you do things right." You should have a checklist of sources to help you assemble documentation for every appeal.

Substantiating sources like the CPT Assistant and the Medicare Carriers Manual are also useful to check in every case, says Cornelia Chavis, billing and insurance manager at Raeford Eye Associates in Raeford, N.C.

Do the Research at the Start

"Up-front research is really important now," says Tammy Tipton, president of Appeal Solutions in Blanchard, Okla. "You really don't have time to gather information before you move on; you really have to do it in the first period before the [carrier-level] reconsideration."

You may want to invest in "appeal management technology," such as software that helps you track your denials so you know how much time has elapsed.

Profit From Shorter Time Frames

Providers have been asking CMS to speed up the appeals process for a long time, so they can't really complain about shortened time frames, 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."

Most denials will be based on a sample of claims rather than a review of all files, or else an automatic edit will deny a whole category of claims, Manthei says. Usually CMS will provide a spreadsheet with all the names and Medicare numbers of the patients affected. So it should be pretty easy to look up files, Manthei says.