Orthopedic Coding Alert

Medicare payers turn appeal rules upside down in 2006 Orthopedic reimbursement professionals responsible for Medicare appeals have a number of changes in store in 2006. Medicare's new Part B fee-for-service appeal procedures went into effect Jan. 1, 2006, so any appeals you-ve filed from that date forward might be handled differently than in the past. Read on to determine how you should change your appeals this year. Independent Contractors Will Now Process Level II Appeals One of the most significant changes to the appeal procedures is that CMS has designated qualified independent contractors (QICs), which are a handful of organizations Medicare has selected to act as independent reviewers of appeals. QIC review replaces the Part B Carrier Hearing in the Medicare fee-for-service appeal process.

DME changes: CMS has designated Q2Administrators as the QIC responsible for reviewing Part B and durable medical equipment (DME) reconsideration requests. Q2A's Ohio office processes Part B reconsiderations for the East region of the United States, and the South Carolina office processes Part B reconsiderations for the West region, as well as DME reconsiderations for the entire United States. Addresses and appeal filing instructions are available at www.q2a.com.

An online search feature at this Web site also allows providers to confirm the date an appeal was received by Q2A, appeal status, and decision deadline.

Under the new regulation, QICs must ensure that medical-necessity denials are reconsidered by a panel of -physicians or other appropriate healthcare professionals.- The panel must also include professionals qualified to assess the regulatory aspects of the claim.

CMS is hopeful that using independent review organizations with physician reviewers will increase confidence in the appeal process and even reduce the number of appeals taken to higher levels.

-We believe that the implementation of requirements that ensure appellants of both the fairness of the decision-making process and the accuracy and consistency of the decisions reached can eventually lead to measurable reductions in the need for the elevation of appeals to the slower, more costly levels of the appeals system (for example, ALJ hearing and MAC or federal court review),- states the appeal regulations interim rule published March 8, 2005.

Any QIC's reconsideration decision must be based on clinical experience and medical, technical and scientific evidence, to the extent applicable to the appeal. QICs are bound by National Coverage Determinations, CMS manuals, and federal Medicare statutes and regulations. QICs must also give substantial deference to local medical review policies and local coverage determinations. However, QICs have some flexibility not to apply local carrier policies if they explain in their decision why they didn't apply the policy. You Must Submit All Evidence by Level II New Medicare appeal regulations require that you must submit all evidence to support the appeal at [...]