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QIO 2 nd Level Medicare Appeals

QIO 2 nd Level Medicare Appeals. Presented by: Cindy L. Reynolds, RHIA 6/4/2014 NYHIMA 79 th Annual Conference. Part A: East and West. East

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QIO 2 nd Level Medicare Appeals

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  1. QIO2nd Level Medicare Appeals Presented by: Cindy L. Reynolds, RHIA 6/4/2014 NYHIMA 79th Annual Conference

  2. Part A: East and West East Includes Alabama, Arkansas, Colorado, Connecticut, Delaware, Florida, Georgia, Louisiana, Maine, Maryland, Massachusetts, Mississippi, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Virginia, Washington DC, West Virginia and Territories of Puerto Rico and Virgin Islands.

  3. Part A: East and West West Includes Alaska, Arizona, California, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Missouri, Montana, Nebraska, Nevada, North Dakota, Ohio, Oregon, South Dakota, Utah, Washington, Wisconsin, Wyoming and the Territories of American Samoa, Guam and the Northern Mariana Islands.

  4. Appeals Process • Appeal Received • Case Scanned or Uploaded into SQID • Triage • Appeal Review • Technical or Clinical Adjudication • Decision Letters • Case Closing

  5. Appeal Request • Valid Redetermination Appeal Request Requirements: • The beneficiary’s name • Medicare Health Insurance Claim (HIC) number • Those specific service(s) and item(s) for which the redetermination was requested and the specific date(s) of service • The name and signature of the party or the representative of the party. • 42 CFR Section 405.944(b)

  6. Appointment of Representative • Appointment of Representative (AOR) form: • Must be included with the Appeal Request if anyone other than the beneficiary or the provider are filing the request for a redetermination or reconsideration. • 42 CFR Section 405.952(b)(2)

  7. Case File • Case file supplied by MAC/AC • RAC

  8. Missing Documentation • Medicare will pay for services that are reasonable and medically necessary for the diagnosis or treatment of a condition, illness or injury in the beneficiary. (Section 1862 (a)(1)(A) of the Social Security Act). When a provider requests a reconsideration, all documentation to support the services being appealed must be included with the request for reconsideration. The provider is responsible for providing sufficient documentation to support that payment is due and the services were medically necessary and provided as billed. (42 CFR Section 424.5(a)(6)).

  9. Types of Appeals That I Perform Part AB of A Inpatient Hospital Imaging/Radiology Home Health Pathology/Laboratory Dismissals Dismissals AC Dismissals AC Dismissals Category III Category III Coding Coding Copay/Deductible Copay/Deductible MUE Drugs Radiation/Chemotherapy/Infusion

  10. Types of Dismissals • Dismissals • AC Dismissals • Missing Claim Element • Untimely • Date Stamp (Calendar date/Julian calendar date) The date stamp is a series of numbers (approximately 10-15 numbers in length). 124300902008202 Does not appear as the standard Gregorian date style. 12/21/2009 Date is based on the Julian Day Calendar. This Julian Calendar date makes up only part of the stamped number series • RAC Demand Letter • FISS Screens • Date claim paid • Good cause arguments

  11. Good Cause Arguments • 40.1.3 - Conditions Which Establish Good Cause • (Rev. 381, Issued: 11-26-04, Effective: 11-26-04, Implementation: 01-10-05) • Good cause may be found when the record clearly shows, or the party alleges and the record • does not negate that the delay in filing was due to one of the following: • Circumstances beyond the individual’s control, including mental or physical impairment (e.g., disability, extended illness), or significant communication difficulties; • The death of the individual or his/her advanced age (advanced age is met automatically if the individual attains age 75 prior to the date services began in the contested claim); • Incorrect or incomplete information about the subject claim furnished by official sources (SSA, CMS, or the FI) to the individual, e.g., whenever a beneficiary is not notified of his/her appeal rights or the time limit for filing; • Delay resulting from efforts by the individual to secure supporting evidence where the individual did not realize that such evidence could be submitted after filing a redetermination; • Unusual or unavoidable circumstances, the nature of which demonstrate that the individual could not reasonably be expected to have been aware of the need to file timely; or • Destruction by fire, or other damage, of the individual’s records when the destruction was responsible for the delay in filing. • NOTE: When the beneficiary’s claim is being handled by a representative of the beneficiary • (§60.5.6), these conditions apply to the representative. For conditions which establish good cause for late filing by providers or suppliers who are representing a beneficiary, see §60.75.

  12. Good Cause Arguments Providers, Physicians or Other Suppliers 240.4 - Conditions and Examples That May Establish Good Cause for Late Filing by Providers, Physicians, or Other Suppliers • (Rev. 695, Issued: 10-07-05; Effective: 05-01-05; Implementation: 01-09-06) • A. Conditions • Good cause may be found when the record clearly shows, or the provider, physician or other supplier alleges and the record does not negate, that the delay in filing was due to one of the following: • Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (CMS, the contractor, or the Social Security Administration) to the provider, physician, or other supplier; or, • Unavoidable circumstances that prevented the provider, physician, or other supplier from timely filing a request for redetermination. Unavoidable circumstances • Encompasses situations that are beyond the provider, physician or supplier’s control, such as major floods, fires, tornados, and other natural catastrophes. • NOTE: Failure of a billing company or other consultant (that the provider, physician, or other supplier has retained) to timely submit appeals or other information is NOT grounds for finding good cause for late filing. The contractor does not find good cause where the provider, physician, or other supplier claims that lack of business office management skills or expertise caused the late filing.

  13. Inpatient Hospital Appeals • Inpatient Hospital • Inpatient versus Observation • Medical Necessity • DRG

  14. Inpatient Service General Rule • Inpatient hospital care, rather than hospital outpatient care, is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. For inpatient care, the medical record must indicate that inpatient care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis. (Medicare Program Integrity Manual, Publication 100-8, Chapter 6, Section 6.5.2) • For inpatient hospital care, admitting physicians or other practitioners should use a 24-hour period as a benchmark, i.e., they should order inpatient admission for patients who are expected to need such care for 24 hours or more, and treat other patients on an outpatient basis. However, the decision whether to admit as an inpatient is a complex medical judgment, which includes consideration of a variety of factors, including: • The patient’s medical history and current medical needs; • The types of facilities available to inpatients and outpatients, the hospital’s bylaws and admission policies, and the relative appropriateness of treatment in each setting; • The severity of the signs and symptoms exhibited by the beneficiary; • The medical probability of something adverse happening to the beneficiary; • The need for diagnostic studies that are appropriately outpatient services to assist in assessing the need for inpatient admission; and • The availability of diagnostic procedures at the time when and at the location where the beneficiary presents. • (Medicare Benefit Policy Manual, Publication 100-2, Chapter 1, Section 10).

  15. Inpatient Care vs. Observation • General Rule • Outpatient observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether a patient will require further treatment as a hospital inpatient, or if s/he can be discharged from the hospital. Thus, a patient receiving hospital observation services may improve and be released, or be admitted as an inpatient. In the majority of cases, the decision whether to admit as an inpatient or discharge can be made in less than 48 hours, usually in less than 24 hours. (Medicare Benefit Policy Manual, Publication 100-2, Chapter 6, Section 20.6; Medicare Claims Processing Manual, Publication 100-4, Chapter 4, Section 290).

  16. DRG’s A Diagnosis-Related Group (DRG), as described by the Official Guidelines for Coding and Reporting, is a system to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use and developed for Medicare as part of the prospective payment system. DRGs are assigned by a "grouper" program based on International Classification of Diseases (ICD) diagnoses, procedures, age, sex, and the presence of complications or co-morbidities. In determining the DRG, the principal diagnosis is considered, which is defined by the Uniform Hospital Discharge Data Set (UHDDS) as, “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” The admitting diagnosis, administered treatments or procedures and secondary diagnoses, defined by UHDDS as, “all conditions that co-exist at the time of admission, that develop subsequently, or that affect the treatment received and / or the length of the hospital stay,” are also utilized in the assignment of the DRG to a claim. (U.S. Department of Health and Human Services, Classification of Diseases, 9th Revision).

  17. Home Health Appeals • Home Health • Plan of Care • Certification • Physician Orders • Face to Face Encounter • OASIS • Homebound vs. Not Homebound • Skilled Nurse Progress Notes • Therapy (PT, OT, ST) Progress Notes • Advance Beneficiary Notice

  18. Home Health General Rule To qualify for Medicare coverage of home health services, a beneficiary must meet each of the following requirements: • Confined to the home; • Under the care of a physician; • In need of skilled services - the beneficiary must need at least one of the following skilled services as certified by a physician in accordance with the physician certification and re-certification requirements for home health services: • Intermittent skilled nursing services that meet the criteria of skilled services; • Physical therapy services that meet the criteria of skilled services; • Speech-language pathology services that meet the criteria of skilled services; and • Continuing occupational therapy services that meet the criteria of skilled services if the beneficiary's eligibility for home health services has been established by virtue of a prior need for intermittent skilled nursing care, speech-language pathology services, or physical therapy in the current or prior certification period. • Under a plan of care; • By whom the services must be furnished - the home health services must be furnished by, or under arrangements made by, a participating Home Health Agency (HHA). • (42 Code of Federal Regulations Section 409.42).

  19. Home Health Plan of Care and Certification • The plan of care certifies that the home health services were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine. The certification of need for home health services must be obtained at the time the plan of treatment is established or as soon thereafter as possible and must be signed by the physician who establishes the plan. The orders on the plan of care must indicate the type of services to be provided to the patient, including the type of professional who will provide the services, the nature of the services or tasks to be provided, as well as the frequency of the services. When services are furnished based on a physician's oral or verbal order, the orders must be signed and dated with the date of receipt by the registered nurse or qualified therapist or medical social worker responsible for furnishing or supervising the ordered services. Oral orders must be countersigned and dated by the physician before the home health agency bills for the care in the same way as the plan of care. The plan of care must be reviewed and signed by the physician who established the plan of care at least every 60 days. Each review of a patient's plan of care must contain the signature of the physician and the date of review. (42 Code of Federal Regulations Section 424.22; Medicare Benefit Policy Manual, Publication 100-2, Chapter 7, Section 30.2).

  20. Home Health Homebound vs. Not Homebound • In order to meet Medicare criteria for coverage of home health services, the physician must certify that the beneficiary is confined to his or her home. An individual does not have to be bedridden to be considered confined to the home. However, the condition of the beneficiary should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. (Medicare Benefit Policy Manual, Publication 100-2, Chapter 7, Section 30.1.1). • Generally speaking, a beneficiary will be considered to be homebound if he or she has a condition due to an illness or injury that restricts the ability to leave their place of residence except with the aid of: supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; or if leaving home is medically contraindicated. If the beneficiary does in fact leave the home, the beneficiary may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, such as attending a religious service, or are attributable to the need to receive health care treatment. Absences attributable to the need to receive health care treatment include, but are not limited to: • Attendance at adult day centers to receive medical care; • Ongoing receipt of outpatient kidney dialysis; or • The receipt of outpatient chemotherapy or radiation therapy. • (Medicare Benefit Policy Manual, Publication 100-2, Chapter 7, Section 30.1.1). • The appellant is responsible for providing the information necessary to establish that the beneficiary is homebound as defined above. (Medicare Benefit Policy Manual, Publication 100-2, Chapter 7, Section 30.1.1).

  21. B of A • Imaging/Radiology • Must have Physician Order • Must have Imaging/Radiology Result • Must have History and Physical prior to date of service • Look up National Coverage Determination (NCD) • Look up Local Coverage Determination (LCD)

  22. B of A • Laboratory/Pathology • Must have Physician Orders • Must have Laboratory/Pathology results • Look up National Coverage Determination (NCD) • Look up Local Coverage Determination (NCD) • Looking at covered diagnoses • Supporting documentation (history and physical, progress note, or other documentation)

  23. MSP Appeals • MSP (Medicare as Secondary Payer) • Malpractice • Wrongful Death • Motor Vehicle Accident • Worker’s Compensation • Estate • Law suits for Asbestos • Unrelated Charges • Wavier

  24. MSP • Wavier When a primary payer makes payment to the beneficiary, Medicare has the right to recover from the beneficiary the primary payment made by Medicare, reduced by a proportionate share of the beneficiary’s procurement costs in obtaining the insurance payment, if any. However, Medicare may waive its right to recovery when the beneficiary meets certain criteria. A waiver may be granted with respect to a beneficiary who is without fault when adjustment or recovery would either defeat the purpose of Title II or Title XVIII of the Social Security Act or would be against equity and good conscience (Social Security Act Section 1870(c); Medicare Secondary Payer Manual, Publication 100-5, Chapter 7, Sections 50.5.4 and 50.6.2).

  25. MSP Wrongful Death • Wrongful death statutes are State laws that permit a person’s survivors to assert the claims and rights that the decedent had at the time of death. These laws may include recovering for the deceased’s medical expenses. When a liability insurance payment is made pursuant to a wrongful death action, Medicare may recover from the payment only if the State statute permits recovery of these medical expenses. Generally, if the statute permits recovery of the deceased’s medical expenses, Medicare may pursue its payments, even if the action fails to explicitly request damages to cover medical expenses. Thus, in that event, even if the entire cause of action sets forth only the relatives and/or heirs damages and losses, then Medicare may still recover its payments. (Medicare Secondary Payer Manual, Chapter 7, Section 50.5.4.1.1). • When State law permits a full recovery of medical damages but limits the amount of the recovery which is payable to creditors as a result of past medical expenses, Medicare may recover against the entire recovery, up to the full amount of past Medicare payments. However, when State law limits the amount of the past medical expenses that may be recovered from the defendant and responsible insurer, Medicare may recover only up to that amount (or the amount of the settlement, if the settlement is less than or equal to Medicare’s claim.) (Medicare Secondary Payer Manual, Publication 100-05, Chapter 7, Section 50.5.4.1.1).

  26. MSP Estate A beneficiary’s death does not materially change Medicare’s interest in recovering its payments made on behalf of the beneficiary while alive. Upon death, the estate of the beneficiary comes into existence by operation of law. An executor or administrator’s sole purpose is to conclude all business and financial matters that still remained at death. Medicare’s interest in the outcome of a third-party liability claim is one of these matters. Therefore, Medicare’s claim is properly asserted against the estate. The right to request a waiver and/or appeal applies equally to the estate if there is a surviving spouse or other eligible dependent under the Social Security Act. Where neither of these parties exists, a waiver may not be granted. (Medicare Secondary Payer Manual, Publication 100-05, Chapter 7, Section 50.5.4.1).

  27. MSP Worker’s Compensation Medicare is secondary to worker’s compensation plans (including black lung benefit programs). Payment under Medicare may not be made for any items and services to the extent that payment has been made or can reasonably be expected to be made for such items or services under a workers' compensation law or plan of the United States or any State. If it is determined that Medicare has paid for items or services that can be or could have been paid under worker’s compensation, the Medicare payment constitutes an overpayment. (Medicare Secondary Payer Manual, Publication 100-05, Chapter 1, Section 10.4).

  28. MSP No-fault Insurance If medical services are covered under a no-fault insurance, that insurance must be billed first. If the insurer does not pay all of the charges, a claim for secondary Medicare benefits can be submitted. Medicare can pay for services related to an accident if benefits are not available under the individual's no-fault insurance coverage because that insurance has paid maximum benefits for the accident on items or services not covered by Medicare or on non-medical items such as lost wages. If there is an indication that the individual has filed, or intends to file, a liability claim against a party that allegedly caused an injury, Medicare Secondary Payer liability provisions may apply. Medicare has a right of recovery from the no-fault insurance, as well as any entity that has received payment directly or indirectly from the proceeds of a no-fault insurance payment. (Medicare Secondary Payer Manual, Publication 100-5, Chapter 2, Sections 60 and 60.1).

  29. MSP General Rule • In general, payment under Medicare may not be made for any items of services to the extent that payment has been made or can reasonably be expected to be made promptly under worker’s compensation, no-fault, or liability insurance. Medicare’s liability for payment in this situation is secondary to that of the primary payer. This exclusion is called the Medicare Secondary Payer (MSP) rule. If it is uncertain whether an insurer will pay, Medicare will make a conditional payment. This payment will be recovered later if it is determined that Medicare’s liability is secondary to that of the primary payer. (Section 1862(b)(2)(B) of the Social Security Act; 42 Code of Federal Regulations Section 411.32(a); Medicare Secondary Payer Manual, Publication 100-05, Chapter 1, Section 10.7.1). • Medicare has a right of action to recover conditional payments from any entity (including beneficiaries, providers, attorneys, state agencies, or private insurers) that has received primary payment. The Medicare Secondary Payer Manual defines “primary payment,” in the context where Medicare is the secondary payer, as “payment by a primary payer for services that are also covered under Medicare.” (42 Code of Federal Regulations Section 411.24; Medicare Secondary Payer Manual, Chapter 1, Section 20).

  30. MSP General Rule – Liability Insurance • Medicare has a right of recovery from the liability insurance as well as any entity that has received payment directly or indirectly from the proceeds of a liability insurance payment. Medicare's recovery right is superior to other entities, including Medicaid, because Medicare’s direct right of recovery is explicitly prescribed in Federal law and other entities’ recovery rights are based on either State law or subrogation rights. (Medicare Secondary Payer Manual, Publication 100-05, Chapter 2, Section 40.1).

  31. Medicare 3 Day Payment Window • Sec.Social Security Act 1886. [42 U.S.C. 1395ww] (a)(1) (4) For purposes of this • section, the term “operating costs of inpatient hospital services” includes all routine operating costs, ancillary service operating costs, and special care unit operating costs with respect to inpatient hospital services as such costs are determined on an average per admission or per discharge basis (as determined by the Secretary), and includes the costs of all services for which payment may be made under this title that are provided by the hospital (or by an entity wholly owned or operated by the hospital) to the patient during the 3 days (or, in the case of a hospital that is not a subsection (d) hospital, during the 1 day) immediately preceding the date of the patient’s admission if such services are diagnostic services (including clinical diagnostic laboratory tests) or are other services related to the admission (as defined by the Secretary). Such term does not include costs of approved educational activities, a return on equity capital, other capital-related costs (as defined by the Secretary for periods before October 1, 1987), or costs with respect to administering blood clotting factors to individuals with hemophilia. In applying the first sentence of this paragraph, the term “other services related to the admission” includes all services that are not diagnostic services (other than ambulance and maintenance renal dialysis services) for which payment may be made under this title that are provided by a hospital (or an entity wholly owned or operated by the hospital) to a patient— • (A) on the date of the patient’s inpatient admission; or • (B) during the 3 days (or, in the case of a hospital that is not a subsection (d) hospital, during the 1 day) immediately preceding the date of such admission unless the hospital demonstrates (in a form and manner, and at a time, specified by the Secretary) that such services are not related (as determined by the Secretary) to such admission.

  32. Signature Requirements • For medical review purposes, Medicare requires that the services provided/ordered be authenticated by the author. The method shall be a handwritten or electronic signature. (Medicare Program Integrity Manual, Publication 100-8, Chapter 3, Section 3.3.2.4).

  33. For Ordering Diagnostic Tests • The rules in 42 CFR 410 and Pub. 100-02, chapter 15, section 80.6.1, state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation by the treating physician (e.g. a progress note) that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature. • All documentation submitted by the provider should be complete and identifiable as to who received the services billed and rendered the services, and where and when the services were rendered. All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. Refer to 42 CFR Section 482.24 (c)(1).

  34. CMS Guidance for Signatures • - A written signature may be received via hard copy mailed correspondence or as part of an appeal request submitted via facsimile. • - An electronic, digital, and/or digitized signature is an acceptable signature on a request submitted via a CMS-approved secure Internet portal/application. The secure Internet portal/application shall include a date, timestamp, and statement regarding the responsibility and authorship related to the electronic, digital, and/or digitized signature within the record. At a minimum, this shall include a statement indicating that the document submitted was, “electronically signed by” or “verified/approved by” etc. • - A stamp signature or other indication that a “signature is on file” on the CMS 20027 form or other documentation (such as a blank claim form) submitted to support the appeal request shall not be considered a acceptable/valid signature regardless of whether the appeal request is submitted via hard copy mail or via facsimile. Medicare Claims Processing Manual, Publication 100-4, Chapter 29, Section 310(b)(3)

  35. Radiation/Chemo/Infusion • Medicare requires documentation to validate services were performed as billed and medically necessary. Dosimetry calculations are coverable when there is documentation to support independent calculations are necessary and ordered by the treating physician. It is usually not appropriate to report this service for calculations that are part of a computerized plan. The reviewed documentation shows stereotactic body radiation therapy (SBRT) was planned for the treatment of lung cancer. No dosimetry reports or treatment planning notes to validate the number of dosimetry calculations and number of beams or arcs were included with the documentation sent for review.

  36. Medically Unlikely Edits • Medicare established the Medically Unlikely Edit (MUE) program in 2007 to reduce the paid claims error rate for Medicare claims. MUEs are designed to reduce errors due to clerical entries and incorrect coding. An MUE is defined as the maximum number of units of service under most circumstances that a provider would report for a procedure or medication for a single beneficiary on a single date of service. All codes do not have an MUE. CMS publishes most MUE values on its website. However, CMS does not publish MUE values for some codes. The MUE values for this latter group of codes are confidential information. The published values may be viewed on the CMS Website at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version Update Changes.html. • An MUE is an automated prepayment edit. Additional information on this may be found in the Internet-Only Manual (IOM) Publication 100-8, Medicare Program Integrity Manual, Chapter 3, Section 3.3.1.2 (B).

  37. Questions ?

  38. Contact Information Cindy L. Reynolds Appeals Officer, Technical Adjudicator Maximus Federal Services 3750 Monroe Avenue, Suite 700 Pittsford, New York 14534-1302 Office: 585-348-3372

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