The success of Medicare appeals frequently hinges on the quality of the supporting documentation. The early and thorough gathering of documentation is even more essential under the new Medicare Claims Appeal Procedures which were partially implemented May 1.
One of the most significant changes to the appeal procedures is the creation of Qualified Independent Contractors. QICs are a handful of organizations Medicare has contracted with to review appeals. The QIC review replaces the Part B Carrier Hearing in the Medicare fee-for-service appeal process.
Under the contracts, QICs must ensure that medical necessity denials will be reconsidered by a panel of “physicians or other appropriate health care professionals.” This gives some hope to providers who, by the nature of the services they provide, find themselves frequently arguing the medical necessity aspect of denied treatment and do not believe carriers give medical necessity appeals an impartial or quality clinical assessment.
“If a panel of physicians review the appeal, hopefully one of them will have experience with ambulance services and the procedures which have to be done in route,” said Candice Anderson, Federal Insurance Manager for 911 Billing in Madisonville, KY.
911 Billing is able to overturn about 80 percent of their Medicare denials utilizing primarily telephone appeals and Level 1 carrier reviews, both of which have changed little under the new provisions. Therefore, they do not expect the Medicare changes to affect their success rate at overturning denied claims. However, they recently participated in a Medicare training regarding the new appeal procedures.
Anderson said many of the changes to the initial appeal process are simply changes in terminology.
For example, the first level of appeal, once referred to as “Carrier Review” is now known as a “Redetermination.” Redeterminations are submitted to the carrier as before. However, the carrier now has only 60 days to make a decision. In the event of a denial, the carrier must provide the clinical or other information used to make the decision.
“Non emergency claims are the ones that we have the most trouble with,” Anderson said. “For those claims, we will be seeking redeterminations which require the carrier to take a look at the situation more closely. We often send a physician certification and run sheet with pertinent information highlighted to get the claim reconsidered.”
Redeterminations are handled separately from “Reopenings.” The Medicare representatives conducting recent training sessions on the new appeal procedures have indicated they expect the two terms to be confused. A Reopening involves a telephone call to the carrier in order to correct minor clerical errors and omissions. Reopenings can also be utilized for submitting missing documentation. Both a Redetermination or a Reopening must be requested within 120 days of the initial determination on the claim. This poses a potential problem in situations where the provider is uncertain whether to request a Redetermination or Reopening as the time for filing each runs consecutively. If in doubt, providers should pursue a Redetermination so that, in the event of a Redetermination denial, the provider will have recourse to pursue a Level 2 appeal.
Providers unsatisfied with a Redetermination decision have 180 days to file the Level 2 appeal, now called a “Reconsideration.” Reconsideration requests must be submitted to the Qualified Independent Contractors specified in the carrier’s redetermination decision.
This is a crucial stage in the entire appeal process with respect to submission of supporting documentation. Under the new law, all evidence to support the appeal must be submitted at the reconsideration level or sooner, absent “good cause for late filing of evidence.” Absent good cause, the failure to submit evidence generally prevents its introduction at subsequent levels of the appeals process. According to the comments recorded in the Federal Register interim rule related to the appeal changes, many healthcare appeal advocates believe that this penalty for failing to present evidence early is harsh. As a result, CMS has added a provision to allow beneficiaries-appellants to submit documentation that was specified as missing in the notice of redetermination at any time during a pending appeal without the need for good cause. However, this exemption does not apply to providers or to beneficiaries who are represented by providers during the appeal process.
The QIC must make a decision on a Reconsideration request in 60 days. If a QIC receives an escalation request notifying them that the deadline is imminent, the QIC must, within five days, complete its reconsideration and notify the parties of the decision or acknowledge the escalation request and forward the case file to an Administrative Law Judge.
Level 3 appeals are still under the jurisdiction of Administrative Law Judges. However, under the old regulations, Level 3 appeals had no time limit for processing. Under the new regulations, all ALJ appeals must be completed within 90 days. Level 4 appeals are to be submitted to the Medicare Appeals Council. As with ALJ reviews, the Medicare Appeals Council now has 90 days to complete reviews. The Final Appeal Level is submission of the appeal in Federal District Court.
Under the old Medicare process, appeals generally took three to five years to reach resolutions at the Medicare Appeals Council level. However, with new time constraints in place at each level, an appeal should take about 18 months to make its way through the entire process.
CMS officials have indicated they do not anticipate that creation of the new entity for hearing medical necessity appeals (QICs) will actually result in a substantive change in the number of favorable decision for providers. However, CMS is hopeful that use of an independent review organization utilizing physician reviewers will increase confidence in the appeal process and even perhaps 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 interim rule. The interim rule was published in March 8, 2005, Vol. 70, No.. 44 edition of the Federal Register.
Further, a QIC’s reconsideration must be based on clinical experience and medical, technical, and scientific evidence, to the extent applicable to the appeal. QIC’s are bound by both National Coverage Determinations, and must give substantial deference to local medical review policies, local coverage determination, CMS manuals and other program guidance applicable to the claim.
A fact sheet regarding these changes can be found at http://www.cms.hhs.gov/appeals/factsheet.pdf.
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