Medicare Claims Appeal Procedures

Lisa BazemoreDirector of Consulting Services

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Objectives

• Review and clarify the steps of the Medicare Appeal Process

• Offer suggestions to assist you to ‘efficiently and effectively’ follow the process with as little confusion as possible

• Assist you to resolve your claims successfully

• Introduce you to the eRehabData’s new tracking system for denials

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Levels in Medicare Appeals Process-

• Additional Development Request Fiscal Intermediary determines whether or not to pay the claim.

• Redetermination FI considers their original determination based on your appeal.

• Reconsideration The Qualified Independent Contractor considers your appeal.

• Hearing The Administrative Law Judge hears your appeal.

• Review The Medicare Appeals Council/Department of Appeals Board will

review the decision of the ALJ. Next, the Federal District Court will hear you case on disputed

claims.

*The Medicare Appeals Process is the same for Medicare A and Medicare B claims

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Reasons for Record Review

• The following list indicates common reasons for Medicare requests for record review:

Coding issues – CPT codes, ICD-9 codes

Local Coverage Determination stipulations

Probes – medical necessity

Utilization issues or Fiscal Intermediary edits

Billing error issues

New provider number

Change in ownership

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Step 1 – The ADR

• The ADR is a written request from the FI for a medical record which will be reviewed before payment is rendered.

• Tips:•Documentation is time sensitive•Note the source of the document•Note the reason for the request if one is given

• Application: The FI will use the documents to determine if the claim

satisfies the Medicare requirements for payment.

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Step 1-ADR Process

• After you have carefully reviewed the FI correspondence:

Pull the Summary Part A Appeal Process Checklist from the AMRPA website.

Review the list of suggested records to return. Be sure each item is in the copies that you will submit.

Alert HIM, billing, finance.

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Step 1-ADR Process

• After you have carefully reviewed the FI correspondence:

Follow the directions from the fiscal intermediary completely.

• Once the record is copied review it again for completeness and accuracy.

• Be sure that each page is copied front and back.• Make a copy of the packet prior to sending it to the FI so

you know exactly what the FI had for review.

Send the record to the FI contact as provided on the letter using a delivery method that offers a tracking number.

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Initial Determination

• Notes about the FI’s determination: FI should respond within 30 - 60 days.

Business Office Manager will receive an explanation of the determination via the facility’s electronic billing system.

• Be aware: You have 120 days from the date of receipt of the

notice. This is presumed to be 5 days after the date of the notice.

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RAC Exception

•RAC Process:

Charts will be requested and reviewed Determination will be rendered and sent to the

provider The provider has 15 days to rebut the decision of the

RAC before the RAC can request funds from the FI The RAC will consider the rebuttal If payment is denied, they will notify the FI

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RAC Exception

•Appeal

Your claim is not a denial until the RAC requests funds from the FI.

The provider will have 120 days to appeal the decision from the date of the remittance advise.

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Step 2 - Redetermination

• The Initial Appeal

If the FI does not believe that your documentation meets their criteria for payment, you will receive notification that the claim was denied.

At this stage you will send your record back to the FI with a cover letter stating why you believe this claim should be paid.

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Step 2 - Redetermination

• The appeal letter The body of the appeal letter should contain the following

information:

•Discuss the reason for the appeal

•Support the medical necessity of the claim

•Explain that the admission was appropriate for your level of care and services were reasonable and necessary

•Defend each week of care

•Cite specific Medicare regulations such as the conditions of participation in your letter where applicable

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Appeal letter

• Open the letter stating: Request re-determination of the claim

The reason for the denial as stated on the original correspondence from the FI

• Utilize the body of the letter to refute the stated reason for the denial

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Appeal letter

• Historical information: Pertinent medical history Co-morbidities that support decision to admit, interventions,

and length of stay Reason for referral to inpatient rehabilitation Specific and pertinent prior level of function

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Appeal Letter

• Example:In summary, Mr. Patient was admitted to Example Rehabilitation on xx/xx/xx through xx/xx/xx following an acute care stay at Example Medical Center after experiencing tremors, generalized weakness and decreased food and liquid intake which led to dehydration and weakness. In addition to these acute issues, Mr. Patient has several underlying medical conditions. Following case review by the intake assessment team, it was felt he was appropriate for a comprehensive rehabilitation program due to his decline in functional status.

 Mr. Patient received a comprehensive, interdisciplinary rehabilitation program including rehabilitation nursing, physical therapy, occupational therapy, and medical social work, psychology, clinical dietician, wound care and therapeutic recreation services. Formal team conference led by a physician occurred on a weekly basis to ensure a coordinated program of care. Mr. Patient participated in an intense individual and group therapy program that allowed him to achieve his established goals. He was discharged safely to home on xx/xx/xx.

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Appeal letter

• Reason for inpatient rehabilitation services: State findings on pre-admission screening that led to decision

to admit. Include a review of assessments: H&P, therapy and nursing

evaluations. Indicate goals. Definitely state why patient requires inpatient rehab to meet

goals. State interventions and how these support need for inpatient

rehab.

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Appeal Letter

• Example:Mr. Patient required the 24-hour availability of a physician with special training or experience in the field of rehabilitation as evidenced by Dr. Other Doctor’s frequent, direct, and medically necessary involvement in his care.

     06/27/2006 – Initial assessment and establishment of plan of care completed by Example, P.A., dictating for attending physician Dr. Other Doctor, as per the history and physical located on pages 15 to 19. The history and physical along with the admission orders found on pages 42 to 44 detail the need for a rehab physician to coordinate and monitor the integrated interdisciplinary rehabilitation program for decline in functional status after alcohol withdrawal with acute delirium tremens, management of hypertension, wound care, pneumonia and prevention of deep venous thrombosis. The individual’s overall medical condition and medical needs identified a risk for medical instability requiring monitoring and involvement by the physician that is generally not available outside the hospital inpatient setting.

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Appeal Letter

• Example continued:06/28/06 – Dr. Doctor, who was covering for Dr. Other Doctor, saw the patient and

assessed his vital signs, lungs, heart, extremities, and laboratory data. He indicated continued management of deep venous thrombosis prophylaxis, chronic atrial fibrillation, hypertension, stage II pressure ulcer on sacrum, treatment for pneumonia, hypothyroidism. He also included consideration for speech therapy consult in the plan. His note can be found on pages 69 and 70 and resulting orders on pages 36 and 37.

 06/29/06 – Mr. Patient was seen by Example, P.A. and Dr. Other Doctor. They assessed his vitals, lungs, abdomen, heart and extremities. The discussed his diagnosis of gout and the intended course of treatment. The note on page 68 indicates continued treatment for rehab and medical issues. Orders can be found on page 35.

   06/30/06 - Dr. Another Example saw the patient and assessed his new onset back pain, vital signs, lungs, heart, abdomen, extremities and lab results. Plan to continue established treatment with trial of medications for back pain. The note can be found on pages 60 and 61 with resultant orders on page 35.

Etcetera for each day of the stay that reflects medical decision-making

The frequent interventions and coordination of care by a physiatrist could not have been provided at a lower level of care, specifically at a skilled nursing facility or by a home health agency.

 

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Appeal letter

• Summary of progress: For each goal or category of goal (I.e. mobility) state status at

referral, status according the admission assessment, and status at discharge.

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Appeal Letter

24 Hour Rehabilitation Nursing Example:Rehabilitation nursing was ordered for Mr. Patient at the time of admission for

bowel and bladder FIM assessment with bowel/bladder program PRN, vital sign monitoring twice a day, monitoring of weight, activity, wound prevention and deep vein thrombosis prevention. See admission orders on page 44.

 On 06/28/2006 nursing completed their assessment and initiated a care plan to address risk of injury, impaired skin integrity, knowledge deficits and ineffective breathing pattern. Details of the rehab nursing plan of care can be found on pages 93 and 94. Nursing also initiated the Pressure Ulcer Prevention protocol, which can be found on page 38, due to Mr. Patient’s significant risk of developing a pressure ulcer.

In ordering rehabilitation nursing at Example Rehabilitation, Dr. Other Doctor was aware that nursing would perform daily assessment and intervention on fall risk, neurological checks, psychosocial status, respiratory status, cardiovascular status, gastrointestinal status, renal status, bowel and bladder status, mobility, wound care, pain, safety and intake and output monitoring. Assessment and intervention on these items can be found in the daily nursing documentation on pages 95 to 227. Additional rehab nursing interventions can be found in the daily nursing narratives on pages 106, 130, 154, 160, 166, 172, 196 and 202.

 

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Appeal Letter

• 24 Hour Rehabilitation Nursing Continued: Additionally Dr. Other Doctor knew that the rehab nurse would provide education

to the patient and family on the areas assessed as appropriate. The interdisciplinary education tracker can be found on pages 393 to 394. The education tracker indicates a rehab nurse provided education on advanced directives, patient rights and responsibilities, diagnosis, plan of care, pain management, nutrition/diet/oral health, self-care, rehab techniques, and current medications. On 07/14/2006 the rehab nurse provided discharge instructions to the patient including diet, bowel/bladder, skin, activity level and restrictions, return appointments, and medications. This education is detailed on page 87 to 88 of the nursing discharge instructions.

 The frequent assessment and interventions by an RN that were utilized throughout

the 24 hour period as well as the specialized patient and family education could not have been provided in a less intensive setting.

 

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Appeal Letter

• Relatively Intense Level of Rehabilitation Services Example:

Mr. Patient’s need for an intense level of rehab services was indicated by the ordering of therapies in the admission orders on page 43. As a standard of care at Example Rehabilitation patients are to receive 3 hours of therapy 5 days a week unless otherwise ordered. Please see the Appendix A attached to this request for redetermination. Per recommendation from *** FI, Example Rehabilitation monitors minutes of therapy delivered to the patient per week. Minutes monitored include services provided from physical, occupational and speech therapies as well as any provision of care from an orthotist or prosthetist. An intense level of rehabilitation services is supported by the delivery of a minimum of 900 minutes per 7 day period, or an average of 129 minutes per day. Mr. Patient received more than 900 minutes of therapy in the first two weeks of his stay. On the last three days of his stay he received greater than 180 minutes per days. These findings indicate compliance with the 3 hour care plan and that an intense level of rehabilitation services was provided.

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Appeal letter

• End with a summary: Reason for referral Prior level of function Skilled interventions Functional progress in spite of complicating conditions Statement of potential outcomes if patient was not seen in inpatient

rehab setting Formally request re-determination

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Appeal Letter

• Example Summary:During Mr. Patient’s stay, he required and received a comprehensive

interdisciplinary rehabilitation program that provided him with at least three hours of therapy a day for at least 5 days a week. A formal team conference was led by myself on a twice weekly basis to ensure a coordinated program of care, as well as to maximize his functional recovery and minimize comorbidities. Functionally, on admission the patient was minimal assist for cognition and ADLs. By time of discharge he was supervision for feeding and grooming and upper extremity dressing, and was able to perform toilet transfer and tub/shower transfer with minimal assist to a bedside commode, as well as a transfer tub bench. He was able to ambulate with a rolling walker up to 115 feet via supervision and do four steps of stairs with minimal assist

Overall, as can be seen, Mr. Patient made excellent progress in his rehabilitation program. He received education on his medical condition and medical psychological support for abstinence regarding his substance abuse. He received aggressive medical management regarding his multiple comorbidities to include delirium tremens, congestive heart failure, pneumonia and hepatic insufficiency. By xx/xx/xx (discharge date), he had made enough progress that we were able to safely discharge him home in good condition. In summary, I do not feel that Mr. Patient could have received the same type of intensive medical, nursing and therapeutic care at any setting other than at Example Rehabilitation. He would not have achieved the progress physically or medically in this short period of time in a lesser intensive level of care.

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Medicare Appeal Decision

• Response to your appeal letter will be received within 60 days

• Billing department will either receives payment electronically and/or there will be a written Medicare Appeal Decision letter detailing the explanation of the unfavorable decision or partial denial (partially unfavorable)

If not received within this time, the billing department should contact the FI

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Step 3 - Reconsideration

• Next appeal level is an ‘on the record’ review by the QIC – Qualified Independent Contractor

Maximus in King of Prussia, Pennsylvania – East Jurisdiction

•26 states•Washington , DC•Puerto Rico, Virgin islands

First Coast Service Options in Jacksonville, Florida – West Jurisdiction

•24 states•Guam, Northern Mariana Islands, American Samoa

• Group of independent health professionals. If a physician issue is involved, a physician will sit on the panel.

• This is meant to be an impartial review.

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Step 3 - Reconsideration

• FI forwards the medical record to the QIC. Sent with a Reconsideration Case Summary Sheet on top of all documents

However, you should send the entire record again to the QIC

• Tips:•Appeal Decision may be several pages in length. Read

it entirely•Request the materials the FI used to support their

decision•Review additional Appeal Rights and respond on the

required form•Respond promptly

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Step 3 - Reconsideration

• This is the last opportunity to submit new documentation to support your claim. If any further documented evidence is available but was not sent prior, submit it with this packet

May want to consider obtaining a signed affidavit from the patient as to their care, benefits from your care and entitlement to the services

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Step 3 - Reconsideration

• QIC renders their decision within 60 days of receipt of your Request for Reconsideration:

Formal QIC decision is sent to the FI

The FI now pays or takes the necessary action to issue payment for the claim

• When the QIC decision is favorable:

Amount to be paid is noted and the FI must pay within 30 days of the QIC’s decision

Within 14 days of the date of payment the FI notifies the QIC of the amount and date of the payment

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Step 3 - Reconsideration

• Medicare Reconsideration Decision will contain information on your claim and further appeal rights

• Next level of appeals is an ‘on the record’ decision by an Administrative Law Judge or a hearing by an Administrative Law Judge

• The ALJ Hearing is initiated by preparing and sending the forms to accompany the request for a hearing within 60 days

• Claim must be equal to or greater than $110 in outstanding payments in order to be appealed at the ALJ level

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Step 4 – Administrative Law Judge

•Facts about the ALJ: Managed by judges who are trained by HHS - the

Department of Health and Human Services

Judges can decide cases without a hearing

Hearing will either be in person, by telephone or via video teleconferencing

Hearing will be a taped, informal discussion of the claim

Judge may be very knowledgeable or require explanation of the claim

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Step 4 - ALJ

• Send the medical record to the OMHA – Office of Hearings and Appeals - even though the QIC will also forward the record:

Irvine, California Cleveland, Ohio Miami, Florida Arlington, Virginia You will be told in your QIC decision letter where to

send your request

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Step 4 - ALJ

•Tips: Be well prepared Review the FI and QIC decisions Understand what you are defending

•Utilization, coding, duration of care•Services provided•Admission itself

Organize the materials

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Step 4 - ALJ

• Judge will render his/ her decision within 90 days

• Additional appeal rights will be explained in the Administrative Law Judge’s decision

• If the denial is overturned, the FI has 30 calendar days to pay the claim from the date of the ALJ’s decision

• If the denial is not overturned, you may request a review by the Department of Appeals Board also referred to as the MAC - the Medicare Appeals Council -in Washington

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Step 5 – Medicare Appeals Council

• At this level of appeal you may group like claims together into one claim.

Submit medical records and DAB form to the MAC

Submit explanation of your reason for an additional review – Legal representation may be needed

Submit within 60 days of receipt of the ALJ Decision

• MAC renders a decision within 90 days of receipt of the request

• If the decision is unfavorable, you may take the appeal to the Federal District Court

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Step 6 – Federal District Court

• This is the final level of appeal All claims will be submitted as one case number You must file a request for a court appearance within

60 days of MAC decision The amount in dispute must be greater than $1130 An attorney will lead this process and represent the

facility in court Staff members, former patients, and other facility

representatives may be encouraged to be witnesses

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Time Frames for Appeals

Level Time Limit to File the Request

Time Limit to Render the Decision

Redetermination

120 days 60 days

Reconsideration

180 days 60 days

ALJ Hearing ** 60 days 90 days

MAC Review 60 days 90 days

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Challenges

Appeal all claims

Track all claims

Adhere to time frames

Receive information from Business/Finance Office in a timely manner

Review carefully all documents from the FI

Respond in a timely manner with the correct documents

Be organized

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Building Blocks

• Communication is critical among hospital departments such as:

• Billing Department or Chief Financial Officer• Health Information Management• Director of Nursing• Chief Executive Officer or Administrator

You need to appoint someone to manage the process. Everyone should know where to send documentation requests.

Since the rehab unit knows how the patient was managed, they should handle the appeal with input from the hospital departments.

All personnel involved in the management of health information (records) and the finances of your organization need to be informed of an ADR and progress made toward resolving outstanding claims.

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Appeals Tracking

• What eRehabData tracks: Type of request Dates of correspondence with the FI Dates of responses from the FI Reason for denial Payment/denial amounts

• How we report it: Active appeals Closed appeals Total cases in appeal at each stage Total dollars in dispute at each stage Total dollars paid at each stage Total dollars denied at each stage

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Tracking Denials

• eRehabData is tracking referrals for 3 reasons For you to effectively manage your denials

To be able to share information among subscribers about what is outstanding in claims, trends in denials, and tricks of the trade for the appeals process

To provide definitive information to CMS about the activity of its contractors

• In order to do this, we need your help Take advantage of the system

Keep the information up to date

Questions?For a soft copy of these slides,

please email me:Lbazemore@erehabdata.com

(202) 588-1766