BIPA/New Medicare Appeals 7/01/05

1. BIPA/New Medicare Appeals7/01/05 Presenter Monica Batton, RN Review Manager Delmarva Foundation for Quality Improvement 1-800-492-5811

2. BIPA BIPA stands for Benefits Information Protection Act 521 42CFR Friday, November 26, 2004 405.1200-1206 Posted on our website at http://www.delmarvafoundation.org/bipa/

3. Providers affected by the new law • Home Health Agencies (HHA’s) • Hospices • Skilled Nursing Facilities (SNF’s) • Comprehensive Outpatient Rehabilitation Facilities (CORF’s)

4. How does the new act affect you as providers? Medicare Part A services are affected The appeal right pertains to fee for service Medicare Beneficiaries

5. Materials Available • http://www.delmarvafoundation.org/bipa/ • Federal Register, Glossary, List of related websites, timing of notices example, and a link to Delmarva webex recordings • 1-800-492-5811 help line provided by Delmarva for Beneficiaries and appeals

6. Memorandums of Agreement • CMS, Center for Medicare and Medicaid Services requires that we as their contracted Quality Improvement Organization for Maryland and the District of Columbia maintain Memorandums of Agreements, (MOA’s) with healthcare providers that we interact with

7. Memorandums of Agreement continued- • Delmarva Foundation presently has MOA’s with HHA, SNF’s, and CORF’s. • Delmarva Foundation has sent out MOA’s for review, signature, and return to all Maryland and District of Columbia Hospices

8. Termination of Medicare Covered Services • Termination of Medicare services is done when they are discharged from a provider • This occurs when there is complete cessation of coverage at the end of the course of treatment. (refer to CMS manual for your agency and definition)

9. Provider Responsibility • Before any termination of services, the provider must deliver a valid written notice to the beneficiary of the decision to terminate services. Mailing the notice does not meet the requirement for BIPA.

10. Timing of Notice • A notice must be issued not later then two calendar days before the proposed end of the services. • Home Health must be delivered two visits before the proposed end of services. • If services are fewer than two days in duration, the notice should be issued at the time of admission.

11. Where can you find coverage information? • We posted a list of website links to CMS manuals that will give you this information for your provider setting.

12. Where can you find an example of a Notice? • We provided a website link on our list of websites that will give you a draft notice example. It has not been finalized by CMS at the time of this webex.

13. Content of the Generic Notice • Date that coverage service ends • Date of beneficiary’s financial liability begins • Description of right to appeal • Description of right to detailed information • Any other information required by CMS • Delmarva contact information

14. Valid Generic Notice • The content of the notice including dates and financial liability is correct. • Beneficiary signed and dated the notice • The notice was delivered within appropriate timeframe.

15. Notice DeliveryWhat if beneficiary refuses to sign? • Note the refusal of the beneficiary to sign on the notice. • The date of the refusal is the date of receipt of the notice. • The notices can’t be mailed to the beneficiary. • Financial Liability • The provider is liable for continued services until two calendar days after the beneficiary receives a valid notice, or until the service termination date, whichever is later.

16. When can the Medicare Beneficiary appeal • CORF’s and HHA’s • When the beneficiary disagrees with termination of service • When a physician determines that failure to continue the service may place the beneficiary’s health at significant risk

17. When can the Medicare Beneficiary appeal • SNF’s and Hospice • When the beneficiary disagrees with the discharge decision

18. How does the beneficiary request an appeal? • The beneficiary (or representative) must request a QIO expedited appeal by calling Delmarva Foundation by noon of the day prior to termination of service at our 800 number listed at the beginning of the slide presentation. 1-800-492-5811

19. Example of Appeal Timelines • Provider issues a notice on 6/1/05 stating that services will end on 6/3/05 • The beneficiary needs to call the Delmarva Foundation to request an appeal by 12Noon of 6/2/05 • The Delmarva Foundation will notify the provider that the beneficiary has requested an appeal and that the provider needs to issue the detailed notice

20. Detailed Notice Timeline • The provider is required to issue the detailed notice by close of business of the day Delmarva notifies you that the beneficiary requested an appeal.

21. Untimely Appeal Request • If a valid notice was issued, the Delmarva Foundation is required to perform the review.

22. Detailed Notice Content • The detailed notice must contain specific and detailed explanation why services are either no longer reasonable and necessary or are no longer covered. • The detailed notice must include a description of any applicable Medicare coverage rules, instruction, or other Medicare policy rules or information about how the beneficiary may obtain a copy of the Medicare policy.

23. Detailed Notice Content continued • The detailed notice must provide facts specific to the beneficiary and relevant to the coverage determination that are sufficient to advise the beneficiary of the applicability of the coverage rule or policy to the beneficiary’s case

24. What the Provider needs to supply to Delmarva Foundation • Supply all parts of the medical record per discussion with Delmarva Foundation at the time of the appeal and include a copy of the generic notice and the detailed notice.

25. What happens if there is a delay in getting information to the Delmarva Foundation? • The provider may be held financially liable in continued coverage if a delay results from the provider failing to supply requested information in a timely manner.

26. What happens once Delmarva Foundation completes the review? • Delmarva Foundation will notify the beneficiary, beneficiary’s physician, and the health care provider. • Initial notification will be by phone • Written notification will follow.

27. What happens if the beneficiary disagrees with the Delmarva Foundation’s decision? • If the beneficiary disagrees with Delmarva’s decision, the beneficiary may request a reconsideration of the decision. • Delmarva Foundation will then instruct the beneficiary to call Maximus.

28. When does coverage stop? • Coverage continues until the date designated on the termination notice, unless the Delmarva Foundation reverses the provider’s service termination decision

29. Billing • Do not bill the beneficiary for any disputed services until the expedited appeal determination process and reconsideration process if applicable has been completed. • The Delmarva Foundation only does the medical review. The Delmarva Foundation does not handle the billing.

30. Billing Questions You should contact the FI for billing questions.

31. Releasing Information to the beneficiary • If the beneficiary requests, the provider must furnish the beneficiary with a copy of or access to any documentation that it sends to the Delmarva Foundation.

32. Delmarva Foundation1-800-492-5811 Monica Batton, RN Review Manager 410-763-6287 mbatton@dfmc.org