Medicare Claims Appeal Procedures Lisa Bazemore Director of Consulting Services

2 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

3 Levels in Medicare Appeals Process- Additional Development Request Redetermination Reconsideration Hearing Review

4 Abbreviations and Terms SSA - Social Security Act (Administration) ADR - Additional Development Request Redetermination MSN - Medicare Summary Notice MRN - Medicare Redetermination Notice AIC - Amount in Controversy Reconsideration - QIC - Qualified Independent Contractor ALJ - Administrative Law Judge MAC - Medicare Appeals Council DAB - Department of Appeals Board Effectuate

5 Building Blocks Communication is critical between you and your hospital departments such as: Business Office Manager or Chief Financial Officer Medical Records Manager Director of Nursing Chief Executive Officer or Administrator  All personnel involved in the management of health information (records) and the finances of your organization need to be informed of an ADR and your progress as you resolve your outstanding claims  Personnel needs to be aware that you should be contacted when a prepayment request is made. This type of correspondence will be submitted to the business office or finance department  Since you know how the patient was managed, the rehab department should handle the appeal with input from the hospital departments

6 Medicare Appeals Levels ADR - Additional Development Request Determination – FI renders an initial decision to pay or deny a claim Redetermination – Initial appeal of a denied claim Reconsideration – ‘On the record’ review by the QIC- Qualified Independent Contractor ALJ - Administrative Law Judge hearing MAC - Review by the Medicare Appeal Council Federal District Court * The Medicare Appeals Process is the same for Medicare A and Medicare B claims

7 Reasons for Record Review The following list indicates reasons for Medicare requests for record review  Coding issues – CPT codes, ICD-9 codes  Utilization issues  Billing issues  New provider number  Change in ownership  FI edits  Probes – medical necessity

8 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: Read the notice carefully Note the source of the document Pay attention to the date of the notice Note the reason for the request if one is given Highlight the time frame to return documents which is usually 45 days The FI will use the documents to determine if the claim satisfies the Medicare requirements for payment

9 Step 1-ADR Process After you have carefully reviewed the FI correspondence:  Contact the various departments that should be informed of the denial (finance, nursing, medical records)  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  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  Sent the record to the FI contact as provided on the letter using a delivery method that offers a tracking number

10 Step 1 - ADR Tracking the claims begins here  After you have responded to the ADR, log the denial into eRehabData  Click on the Appeal button on the Management Screen  Go to the patient’s record and click on the “Appeals” tab  You will be asked to fill in the following information: Level of Appeal Date noted on the ADR letter that you received Type of Request (FI or RAC) Which FI or RAC Facility Contact Person Date that you submitted the ADR to the FI

11 Initial Determination Notes about the FI’s determination:  FI will respond within days  Business Office Manager will receive a written explanation of the determination via the facility’s electronic billing system Tips:  Request the ‘exact’ date of the determination.  From that date your time to appeal starts days from the date of receipt of the notice. This is presumed to be 5 days after the date of the notice Tracking:  Open the record in eRehabData and enter the following information: Date determination received Outcome: favorable or unfavorable Reason for denial from the list provided Amount paid and/or denied Days to respond from the letter that you received from the FI

12 Step 2 - Redetermination The Initial Appeal  If the FI does not believe that your claim meets their criteria for payment, you will receive a letter stating that the claim was denied  At this stage you will send your record with a cover letter stating why you believe this claim should be paid  Necessary patient identification items to include in the heading of the letter: Provider name Provider number Beneficiary name Beneficiary’s HIC/Medicare number Dates of service from field 6 of the UB-92 Services that are being appealed – IRF admission and stay

13 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

14 Step 2 - Redetermination The redetermination packet should include:  CMS as the first page of your packet  Appeal letter  All documentation that was sent for the ADR  Send this packet to the address given in the determination letter using a delivery method that offers document tracking Tracking  Enter the date that you sent the appeal to the FI in the patient’s record in eRehabData

15 Medicare Appeal Decision Response to your appeal letter will be received within 60 days Business Office Manager either receives payment electronically and/or there will be a ‘written’ Medicare Appeal Decision letter detailing the explanation of the partial denial (partially unfavorable) or totally unfavorable decision  If not received within this time, the BOM should contact the FI Tracking:  Open the record in eRehabData and enter the following information: Date determination received Outcome: favorable or unfavorable decision Reason for denial from the list provided Amount paid and/or denied Days to respond from the letter that you received from the QIC

16 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

17 Step 3 - Reconsideration The goal at the QIC stage is to refute the FI’s decision for the continued denial 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 Request the materials the FI used to support their decision Review additional Appeal Rights Complete Reconsideration Request Form that accompanied the Appeal Decision to initiate appeal to next level Respond promptly

18 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 o btaining a signed affidavit from the patient as to their care, benefits from your care and entitlement to the services Be sure that all necessary items are included: Provider name Provider number Beneficiary name Beneficiary’s HIC/Medicare number Dates of service from field 6 of the UB-92 Services that are being appealed – IRF admission and stay Signature and date of person submitting the request

19 Step 3 - Reconsideration Tracking  Submit the request within 180 days of receiving the Medicare Appeal Decision  Enter the date that request was sent to the QIC in eRehabData within the patient record on the appeal tab

20 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 ‘effectuates’ 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

21 Step 3 - Reconsideration Medicare Reconsideration Decision will contain information on your claim and further appeal rights Tracking:  Open the record in eRehabData and enter the following information: Date QIC determination received Outcome: favorable or unfavorable decision Reason for denial from the list provided Amount paid and/or denied Days to respond from the letter that you received from the FI Next level of appeals is an ‘on the record’ decision by an Administrative Law Judge or a hearing by an Administrative Law Judge

22 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

23 Step 4 - ALJ The ALJ Hearing is initiated by preparing and sending the forms to accompany the request for a hearing  CMS Appointment of Representative (7/05) You have 60 days to request an ALJ Hearing Claim must be equal to or greater than $110 in outstanding payments in order to be appealed at the ALJ level 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

24 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 Tracking:  Enter the date that request was sent to the ALJ in eRehabData within the patient record on the appeal tab

25 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 Tracking:  Open the record in eRehabData and enter the following information: Date of ALJ Hearing Date determination received Outcome: favorable or unfavorable decision Reason for denial from the list provided Amount paid and/or denied Days to respond from the letter that you received from the ALJ

26 Step 4 - ALJ 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

27 Step 5 – Medicare Appeals Council At this level of appeal you may group like claims together into one claim.  Submit medical record and DAB form 101 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 Tracking  Enter the date that request was sent to the MAC in eRehabData within the patient record on the appeal tab

28 Step 5 - MAC MAC renders a decision within 90 days of receipt of the request Tracking  Open the record in eRehabData and enter the following information: Date of MAC Review Date determination received Outcome: favorable or unfavorable decision Reason for denial from the list provided Amount paid and/or denied Days to respond from the letter that you received from the MAC If the decision is unfavorable, you may take the appeal to the Federal District Court

29 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 effective January 1, 2007 with an implementation date of July 1, 2007  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 Tracking  Enter the date that request was sent to the FDC in eRehabData within the patient record on the appeal tab

30 Step 6 - FDC Once a decision is rendered, enter the final information in eRehabData  Open the record and enter the following information: Date of FDC appearance Date determination received Outcome: favorable or unfavorable decision Reason for denial from the list provided Amount paid and/or denied

31 Time Frames for Appeals LevelTime Limit to File the Request Time Limit to Render the Decision Redetermination120 days60 days Reconsideration180 days60 days ALJ Hearing **60 days90 days MAC Review60 days90 days

32 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

33 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

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