Introductory Guide to SNF
Medicare Appeals
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. ...
Speaker Bio (Elisa Bovee)
Vice President of Operations for Harmony Healthcare International (HHI), an industry
leader in L...
Introductory Guide to SNF
Medicare Appeals
Disclosures: The planners and presenters of this educational activity have no
r...
Denials Management:
From ADR to ALJ
Either write something worth reading or do
something worth writing.
-Ben Franklin
Copy...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
A Drive Down
Reimbursement Memory Lane
5
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
Medicare
Federal Health Insurance Program
Titl...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
The Medicare Structure
Guidelines directed by ...
What is Skilled Care?
Anchoring the Skill
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
Copyright © 2013 All Rights Reserved
Medicare Requirements
The patient requires Skilled Nursing
Services or Skilled Rehabi...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
Medicare Eligibility
Treated for a condition w...
Copyright © 2013 All Rights Reserved
Medicare Requirements
The patient requires these skilled
services on a daily basis (s...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
Federal Regulations
Not always written clearly...
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
Federal Regulations
Medicare offers five level...
Additional Development Requests
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
RAC Program
The Centers for Medicare & Medicaid
Services has ordered recovery auditors to
cease in their requests for medi...
Additional Development Requests
Medicare Contractors send providers
additional development request (ADR)
letters requestin...
Additional Development Requests
Do not submit replacement/duplicate
claims for the ones pending in medical
review
The subm...
Additional Development Requests
When the claim is finalized, the claim
will have paid in full or part, or denied.
If you d...
Additional Development Requests
After the 45th day, if the documentation
needed to make a medical
determination is not rec...
Additional Development Requests
CMS guidelines allow contractors the
time frame of 60 days to complete the
review from the...
Harmony Healthcare International
ADR Response
And
Appeal Packages
Harmony Healthcare International, Inc. 21Copyright © 201...
The Appeal
In order to effectively manage a Medicare
denial, the facility must work as a team to
gather pertinent informat...
The Appeal
The following team members are beneficial in this
process:
MDS Coordinator
Director of Nursing
Unit Managers (c...
The Appeal
It is important to read the ADR or denial
letter thoroughly as the letters will assist
the facility in gatherin...
How Does Your Team Measure Up?
Take the Harmony Healthcare International
(HHI) Denied Claims Appeals Process
Proficiency E...
How Does Your Team Measure Up?
1. To what degree does your facility have a
monthly Triple Check system in place?
a. The te...
How Does Your Team Measure Up?
2. ICD-9 codes on the UB-04 are determined
using which of the following methods?
a. The ICD...
How Does Your Team Measure Up?
3. Which item best represents how therapy
evaluations support a decline in function?
a. The...
How Does Your Team Measure Up?
4. Accuracy on the Physician Certification Forms to
reflect the skilled care provided by th...
ADR/Help Letter Checklist
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30
HELP LETTER REVIE...
The Appeal Package
List of items typically requested:
Initial MDS and any MDS that corresponds to
the billed dates of serv...
The Appeal Package
Items to include
Include all information in the medical
record from the look back period
MD re-certific...
The Appeal Package
Items to include
Pre admission data
Hospital Records that validate a qualifying stay
Daily Nurses notes...
The Appeal Package
Items to include
Documentation of all therapies provided
Evidence of MD supervision
Evaluations
Progres...
The Appeal Package
Items to include
Diagnostic testing and lab work
Documentation of adjustment to HIPPS codes
resulting f...
The Appeal Package
Important to know the consequences if
the facility does not submit all
necessary paperwork
Facility nee...
The Appeal Package
Each team member should review the
package as a whole
The team leader should have a final
look prior to...
Appeals Process
PREP
Include a statement of position letter with
the medical record documentation to the
reviewing agency ...
Monitor the Appeal
Internal tracking system to monitor
When ADR or denial was received
When package was sent out
Final res...
Monitor the Appeal
Harmony Healthcare International, Inc. 40Copyright © 2012 All Rights Reserved
Technical Denial Reasons
Response to Additional Documentation Request
(ADR) did contain documentation requested
Documentat...
Clinical Denial Reasons
Documentation did not support medical
necessity
Documentation does not support daily
skilled inter...
Appeal Rights
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
Appeal Rights
Medicare offers five levels in the Part A and Part
B Appeals Process:
1. Redetermination by a MAC
2. Reconsi...
Appeal Rights
Right to Appeal
All appeal requests must be
made in writing
Harmony Healthcare International, Inc. 45Copyrig...
Appeal Rights
Redetermination
A review of the claim by the MAC utilizing
personnel who are different from the
personnel wh...
Appeal Rights
Reconsideration
If the facility is dissatisfied with result of
redetermination, they may request a
reconside...
Appeal Rights
ALJ Hearing
If at least $130 remains in controversy
following the QIC’s decision, the facility
may request a...
Appeal Rights
Medicare Appeals Council Review
If the facility is dissatisfied with the ALJ’s
decision, may request review ...
Appeal Rights
Medicare Appeals Council Review
Generally, the Appeals Council will issue a
decision within 90 days of recei...
Appeal Rights
Medicare Appeals Council Review
If at least $1,260 or more is still in
controversy following the decision, t...
Appeal Rights
Don’t get discouraged
ALJ is an impartial decision maker
The facility will get a chance to clearly
state why...
Harmony Healthcare International
Redetermination
and
Reconsideration
Harmony Healthcare International, Inc. 53Copyright © ...
Redetermination and Reconsideration
If a claim is initially denied, there is
action the facility can take
The first stage ...
Redetermination
An examination of a claim by a review
agency who is different from the agency
who made the initial determi...
Redetermination
Request for redetermination may be
filled on Form CMS-20027 available at
http://www.cms.hhs.gov/CMSForms/C...
Redetermination
Requests not made on Form CMS-20027
must include:
Beneficiary name
Medicare Health Insurance Claim (HIC)
n...
Redetermination
Requests not made on Form CMS-20027
must include
Name and signature of the party or the
representative of ...
Redetermination
Include an appeal letter that outlines
the argument for coverage
Brief explanation of the hospitalization ...
Redetermination
Appeal Letter
An explanation of skilled therapy
services provided to the patient
Medicare guidelines used ...
Redetermination
Any additional supporting documentation
not submitted during the Help letter phase
from the medical record...
Redetermination
Contractors will generally issue a
decision within 60 days of receipt of
redetermination request in the fo...
Reconsideration
If the request for redetermination results in a
denial, a reconsideration can be requested
A QIC will cond...
Reconsideration
A written reconsideration request must
be filed within 180 days of receipt of the
redetermination
Instruct...
Reconsideration
If Form 20033 is not used, request must
contain:
Beneficiary name
Medicare Health Insurance Claim (HIC)
nu...
Reconsideration
Documents to include
Name and signature of the party or
the representative of the party
(usually the admin...
Reconsideration
Include a letter outlining the argument for
payment
Brief explanation of the hospitalization (if one
occur...
Reconsideration
The request should clearly explain why
the facility disagrees with the
redetermination
A copy of the MRN, ...
Reconsideration
If facility submits documentation after
the reconsideration request has been
filed, the QIC can extend the...
Reconsideration
Evidence not submitted at the
reconsideration level may be
excluded from consideration as
subsequent level...
Reconsideration
Reconsiderations are conducted on-the-
record; and in most cases, the QIC will
send its decision to all pa...
Reconsideration
If the QIC cannot complete its
decision in the applicable
timeframe, it will inform the
appellant of their...
Administrative Law Judge (ALJ)
Hearings
Harmony Healthcare International, Inc. 73Copyright © 2012 All Rights Reserved
ALJ Overview
After the redetermination and
reconsideration process, if at least $130
remains in controversy following the ...
ALJ Overview
A letter to request the ALJ hearing
should simply highlight the most
pertinent reasons justifying
payment
Har...
ALJ Overview
ALJ hearings are generally held by
video-teleconference (VTC) or by
telephone
If the facility prefers not to ...
ALJ Overview
The ALJ will determine whether an in-
person hearing is warranted on a case-by-
case basis
Facilities may als...
ALJ Overview
ALJ will generally issue a decision within 90 days of
receipt of the hearing request
The timeframe may be ext...
ALJ Overview
If the ALJ does not issue a decision
within the applicable timeframe,
you may ask the ALJ to escalate the
cas...
ALJ
Hearing Preparation
Harmony Healthcare International, Inc. 80Copyright © 2012 All Rights Reserved
ALJ Hearing Preparation
Appeal Process
Discuss and study CMS Guidelines
Discuss type of ALJ hearing
(video, phone, in pers...
ALJ Hearing Preparation
Team Preparation
Medical record review
Outline of speaking points
Select a point person for the
he...
ALJ Hearing
Hearing Process
Prepare the facility designated hearing
room for video or phone hearings
Judge’s assistant wil...
ALJ Hearing
Organize documentation
Keep pertinent notes or forms at your
finger tips
Number the pages for reference
Have t...
ALJ Hearing
Be prepared to answer questions prepared
by the Judge
Why did the patient require skilled therapy
when they we...
ALJ Hearing
Be prepared to answer questions asked
by the Judge
When did the patient get discharged
from therapy services?
...
Strategies for Providers
Provide clinically appropriate care
Document
Medical necessity
Deficits
Outcomes
Meet technical r...
Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
www.Harmony-Healthcare.com
EBovee@Harmony-Healthcare...
Harmony Healthcare International
Have you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM
EVALUATION
o...
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Introductory Guide to SNF Medicare Appeals

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A comprehensive review of the Medicare appeal process. Appropriate for all SNF nursing staff, management, and therapy professionals. The presentation discusses the various levels of Provider Medicare appeal rights. The presentation further explains how facilities can thoroughly manage the appeal process and participate in a successful ALJ hearing.

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Introductory Guide to SNF Medicare Appeals

  1. 1. Introductory Guide to SNF Medicare Appeals HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Elisa Bovee, MS OTR/L Vice President of Operations
  2. 2. Speaker Bio (Elisa Bovee) Vice President of Operations for Harmony Healthcare International (HHI), an industry leader in Long-Term Care consulting on a national level Over 20 years of experience in the long-term care industry, practicing and providing consulting services related to therapy services and Medicare Regulations and Guidelines Manager of a diversified team of consultants who have extensive knowledge in the areas of MDS 3.0, RUG-IV, Documentation, Therapy Program development and state-specific Medicaid Case mix Appeals Coordinator for a National nursing home company Proficient in Medicare Denials Professional in Reimbursement guidelines for Medicare and Medicaid in the skilled nursing facility Former Director of Education and Training and Regional Consultant for Harmony Healthcare International Author of many articles featured in select long-term care industry trade magazines Provider of public and private education on a national level focused on a multitude of topics including Medicare regulations, and therapy solutions for case management in the SNF Provider of extensive training for MDS Coordinators, Therapy Directors and Rehabilitation Staff on MDS coding, RUG-IV Intimacy, Skilled Nursing Therapy Documentation in the SNF and Denials Management for the SNF Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. Introductory Guide to SNF Medicare Appeals Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose Planners: Elisa Bovee, MS, OTR/L Diane Buckley, BSN, RN, RAC-CT Beckie Dow, RN, RAC-MT Keri Hart, MS CCC, SLP, RAC-CT Kristen Mastrangelo, OTR/L, MBA, NHA Christine Twombly, RNC, RAC-MT, LHRM Presenter: Elisa Bovee, MS OTR/L Vice President of Operations Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. Denials Management: From ADR to ALJ Either write something worth reading or do something worth writing. -Ben Franklin Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
  5. 5. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. A Drive Down Reimbursement Memory Lane 5
  6. 6. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. Medicare Federal Health Insurance Program Title XVIII (Medicare) Into effect July 1, 1966 Cost Based Ancillary Expense plus A & G Square footage Treated without minute criterion Patient outcomes LOCC RCL/Exceptions/Exemptions CDP: Certified Distinct Part 6
  7. 7. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. The Medicare Structure Guidelines directed by CMS Many different entities (ZPIC, RAC, OIG, DOJ) CMS allows the MAC to function in an Administrative capacity between healthcare providers and the government Kathleen Sebelius, Secretary (HHS) Health and Human Services, 2013 7
  8. 8. What is Skilled Care? Anchoring the Skill Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. Copyright © 2013 All Rights Reserved Medicare Requirements The patient requires Skilled Nursing Services or Skilled Rehabilitation Services (i.e., services that must be performed by or under the supervision of professional or technical personnel) (See §214.1 – 214.3) Harmony Healthcare International, Inc. 9
  10. 10. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. Medicare Eligibility Treated for a condition which was treated during a qualified stay…or… which arose while in a SNF for a treatment of condition for which the beneficiary previously was treated in a hospital For Example: Fractured hip develops pneumonia secondary to immobility 10
  11. 11. Copyright © 2013 All Rights Reserved Medicare Requirements The patient requires these skilled services on a daily basis (see §214.5) Daily Nursing Notes Treatment Sheets Harmony Healthcare International, Inc. 11
  12. 12. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. Federal Regulations Not always written clearly Not always written concisely Not always written definitively Do not always make logical sense Change on a regular basis! 12
  13. 13. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. Federal Regulations Medicare offers five levels in the Part A and Part B appeals process. The levels, listed in order, are: Redetermination by a MAC Reconsideration by a QIC Hearing by an Administrative Law Judge (ALJ) Review by the Medicare Appeals Council within the Departmental Appeals Board, (hereinafter “the Appeals Council”) Judicial review in U.S. District Court 13
  14. 14. Additional Development Requests Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. RAC Program The Centers for Medicare & Medicaid Services has ordered recovery auditors to cease in their requests for medical records effective CMS said the document requests and auditing would resume when the new RAC contracts are awarded, but did not specify the status and start dates for the new contracts. Harmony Healthcare International, Inc. 15Copyright © 2012 All Rights Reserved
  16. 16. Additional Development Requests Medicare Contractors send providers additional development request (ADR) letters requesting additional documentation The ADR letters will be mailed and /or the claim in question will be in status location S B6001 that identifies claims in FISS that are in an ADR status/location Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. Additional Development Requests Do not submit replacement/duplicate claims for the ones pending in medical review The submission of replacement/duplicate claims will result in claim denial, rejection or recoupment and will This will p r o l o n g the medical review process Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  18. 18. Additional Development Requests When the claim is finalized, the claim will have paid in full or part, or denied. If you disagree with the decision, you can request a redetermination/1st level of appeal within 120 days of the determination (date on the remittance advice). Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
  19. 19. Additional Development Requests After the 45th day, if the documentation needed to make a medical determination is not received, the claim may be denied as records not received timely and these claim denials are issued with Remittance Advice Code N102/56900 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  20. 20. Additional Development Requests CMS guidelines allow contractors the time frame of 60 days to complete the review from the date on which the last of the requested medical records is received. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  21. 21. Harmony Healthcare International ADR Response And Appeal Packages Harmony Healthcare International, Inc. 21Copyright © 2012 All Rights Reserved
  22. 22. The Appeal In order to effectively manage a Medicare denial, the facility must work as a team to gather pertinent information Assign a team leader to oversee the preparation of the denial package All members of the team should review the medical record to ensure completeness Harmony Healthcare International, Inc. 22Copyright © 2012 All Rights Reserved
  23. 23. The Appeal The following team members are beneficial in this process: MDS Coordinator Director of Nursing Unit Managers (consider) Restorative Nursing program Manager Director of Therapy Any therapy professionals involved in the patient’s care Social Services Dietary Additional team members who participated in care Harmony Healthcare International, Inc. 23Copyright © 2012 All Rights Reserved
  24. 24. The Appeal It is important to read the ADR or denial letter thoroughly as the letters will assist the facility in gathering the appropriate information Review the list of items provided in the decision statement to include in the medical record Consider additional info not listed that will support the services provided Harmony Healthcare International, Inc. 24Copyright © 2012 All Rights Reserved
  25. 25. How Does Your Team Measure Up? Take the Harmony Healthcare International (HHI) Denied Claims Appeals Process Proficiency Exam http://cdn2.hubspot.net/hub/56632/file- 285885026-pdf/DenialGraderWB.pdf Harmony Healthcare International, Inc. 25Copyright © 2012 All Rights Reserved
  26. 26. How Does Your Team Measure Up? 1. To what degree does your facility have a monthly Triple Check system in place? a. The team meets every month to review UB-04s, MDS assessments, and Therapy Billing Logs b. The team tries to meet each month, but sometimes it’s hard to get the team together c. The Billing Department double checks everything d. There is no a Triple Check system in place Harmony Healthcare International, Inc. 26Copyright © 2012 All Rights Reserved
  27. 27. How Does Your Team Measure Up? 2. ICD-9 codes on the UB-04 are determined using which of the following methods? a. The ICD-9 coding is updated monthly as the patient’s skilled nursing and therapy needs change b. The ICD-9 coding is determined shortly after the patient is admitted based on nursing and therapy needs c. The ICD-9 coding is discussed by the team prior to end of month billing to ensure codes reflect the reason for hospitalization and skilled nursing needs d. ICD-9 codes on the UB-04 are not a priority and likely do not reflect the patient’s skilled needs Harmony Healthcare International, Inc. 27Copyright © 2012 All Rights Reserved
  28. 28. How Does Your Team Measure Up? 3. Which item best represents how therapy evaluations support a decline in function? a. Therapy evaluations document a clear prior level of function and a significant decline from the patient’s highest practicable level of function b. Therapy evaluations document a clear prior level of function, but not all functional areas are tested on evaluation c. Therapists are not always able to obtain a prior level of function or not all functional areas are tested on evaluation d. Evaluations lack the details required to support a decline in function Harmony Healthcare International, Inc. 28Copyright © 2012 All Rights Reserved
  29. 29. How Does Your Team Measure Up? 4. Accuracy on the Physician Certification Forms to reflect the skilled care provided by the Nursing and Therapy departments is achieved through which process below? a. Skilled qualifiers notated on the Certification forms are discussed as an interdisciplinary team and reflect the details of both nursing and therapy skilled services b. Skilled qualifiers are pulled from the hospital discharge summary; therapy disciplines are also listed if the patient is evaluated per physician orders c. Physician ordered therapies are listed on the form; the skilled nursing needs are only included if therapy is not involved d. Physician Certification Forms are not in use Harmony Healthcare International, Inc. 29Copyright © 2012 All Rights Reserved
  30. 30. ADR/Help Letter Checklist Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30 HELP LETTER REVIEW CHECK LIST Period Skilled Nursing Chart Review: From: __________________ To: _________________ Medicare Admission Date: ___________ Diagnosis: ________________________________ MDS Reference Dates Review 5 day 14 day 30 day 60 day 90 day SOT/EOT OMRA ARD Billing Dates RUG/HIPPS COT COT COT COT COT COT ARD Billing Dates RUG/HIPPS ICD-9 Codes ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
  31. 31. The Appeal Package List of items typically requested: Initial MDS and any MDS that corresponds to the billed dates of service and look back All physician documentation for dates of service in question Physician’s orders MD certifications MD progress notes History and Physical Harmony Healthcare International, Inc. 31Copyright © 2012 All Rights Reserved
  32. 32. The Appeal Package Items to include Include all information in the medical record from the look back period MD re-certifications for skilled stay for billed dates: If certification is signed by a NP, be aware that there may be a request for the facility to submit an attestation letter verifying no direct or indirect employment relationship with the SNF Harmony Healthcare International, Inc. 32Copyright © 2012 All Rights Reserved
  33. 33. The Appeal Package Items to include Pre admission data Hospital Records that validate a qualifying stay Daily Nurses notes MDSC notes Case Manager notes Care Plan MAR and TAR Harmony Healthcare International, Inc. 33Copyright © 2012 All Rights Reserved
  34. 34. The Appeal Package Items to include Documentation of all therapies provided Evidence of MD supervision Evaluations Progress notes and Therapy billing logs Any other documentation that relates to the condition for which services were rendered that skilled the patient for Medicare Part A services in the Skilled Nursing Facility Harmony Healthcare International, Inc. 34Copyright © 2012 All Rights Reserved
  35. 35. The Appeal Package Items to include Diagnostic testing and lab work Documentation of adjustment to HIPPS codes resulting from MDS corrections Signature log for all staff members documenting in the medical record during the dates in question, including printed name, credentials and handwritten signatures Harmony Healthcare International, Inc. 35Copyright © 2012 All Rights Reserved
  36. 36. The Appeal Package Important to know the consequences if the facility does not submit all necessary paperwork Facility needs to review the packet carefully to avoid a technical denial based on missing information including signatures Harmony Healthcare International, Inc. 36Copyright © 2012 All Rights Reserved
  37. 37. The Appeal Package Each team member should review the package as a whole The team leader should have a final look prior to submitting the appeal PREP Letter Proper Reimbursement Explanation Paper Always keep a copy of the packet sent to the reviewing agency Harmony Healthcare International, Inc. 37Copyright © 2012 All Rights Reserved
  38. 38. Appeals Process PREP Include a statement of position letter with the medical record documentation to the reviewing agency explaining the services provided to the patient Harmony Healthcare International, Inc. 38Copyright © 2013 All Rights Reserved
  39. 39. Monitor the Appeal Internal tracking system to monitor When ADR or denial was received When package was sent out Final results of the review Sample tracking form included in handouts Harmony Healthcare International, Inc. 39Copyright © 2012 All Rights Reserved
  40. 40. Monitor the Appeal Harmony Healthcare International, Inc. 40Copyright © 2012 All Rights Reserved
  41. 41. Technical Denial Reasons Response to Additional Documentation Request (ADR) did contain documentation requested Documentation not received within requested time frame Physician Certification not signed or missing Therapy Billing logs do not support billing Part A – MDS Assessment Part B - 8 Minute Rule Illegible documentation Hospital documentation was not submitted Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 41
  42. 42. Clinical Denial Reasons Documentation did not support medical necessity Documentation does not support daily skilled intervention by a qualified therapist Documentation in the medical records must support continued progress Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
  43. 43. Appeal Rights Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  44. 44. Appeal Rights Medicare offers five levels in the Part A and Part B Appeals Process: 1. Redetermination by a MAC 2. Reconsideration by a QIC 3. Hearing by an Administrative Law Judge (ALJ) 4. Review by the Medicare Appeals Council, within the Department Appeals Board 5. Judicial review in U.S. District Court Harmony Healthcare International, Inc. 44Copyright © 2012 All Rights Reserved
  45. 45. Appeal Rights Right to Appeal All appeal requests must be made in writing Harmony Healthcare International, Inc. 45Copyright © 2012 All Rights Reserved
  46. 46. Appeal Rights Redetermination A review of the claim by the MAC utilizing personnel who are different from the personnel who made the initial determination The appellant (individual filing the appeal) has 120 days from the date of receipt of initial denial to file an appeal A minimum monetary threshold is not required to request a redetermination Harmony Healthcare International, Inc. 46Copyright © 2012 All Rights Reserved
  47. 47. Appeal Rights Reconsideration If the facility is dissatisfied with result of redetermination, they may request a reconsideration A Qualified Independent Contractor (QIC) will conduct the reconsideration The reconsideration process is an independent review of medical necessity by a panel of physicians or other health care professionals A minimum monetary threshold is not required to request a reconsideration Harmony Healthcare International, Inc. 47Copyright © 2012 All Rights Reserved
  48. 48. Appeal Rights ALJ Hearing If at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration The facility must also send a notice of the ALJ hearing request to the QIC and verify this on the hearing request form or in the written request Harmony Healthcare International, Inc. 48Copyright © 2012 All Rights Reserved
  49. 49. Appeal Rights Medicare Appeals Council Review If the facility is dissatisfied with the ALJ’s decision, may request review by Medicare Appeals Council No requirements regarding the amount of money in controversy The request must be submitted in writing within 60 days of receipt of ALJ’s decision and must specify the issues and findings that are being contested Harmony Healthcare International, Inc. 49Copyright © 2012 All Rights Reserved
  50. 50. Appeal Rights Medicare Appeals Council Review Generally, the Appeals Council will issue a decision within 90 days of receipt of a request. Timeframe may be extended for various reasons, such as the case being escalated from an ALJ hearing If a decision is not issued within timeframe, facility may ask the Appeals Council to escalate the case to the Judicial Review level Harmony Healthcare International, Inc. 50Copyright © 2012 All Rights Reserved
  51. 51. Appeal Rights Medicare Appeals Council Review If at least $1,260 or more is still in controversy following the decision, the facility may request judicial review before a U.S. District Court Judge Appellant must file request for review within 60 days of receipt of the Appeals Council’s decision Harmony Healthcare International, Inc. 51Copyright © 2012 All Rights Reserved
  52. 52. Appeal Rights Don’t get discouraged ALJ is an impartial decision maker The facility will get a chance to clearly state why daily skilled care was provided and meets the Medicare regulations for skilled nursing/rehab care under the Medicare program in this setting Harmony Healthcare International, Inc. 52Copyright © 2012 All Rights Reserved
  53. 53. Harmony Healthcare International Redetermination and Reconsideration Harmony Healthcare International, Inc. 53Copyright © 2012 All Rights Reserved
  54. 54. Redetermination and Reconsideration If a claim is initially denied, there is action the facility can take The first stage is the Redetermination The next step is a Reconsideration Harmony Healthcare International, Inc. 54Copyright © 2012 All Rights Reserved
  55. 55. Redetermination An examination of a claim by a review agency who is different from the agency who made the initial determination The facility has 120 days from the date of receipt of the initial claim determination to file an appeal A minimum monetary threshold is not required to request a determination Harmony Healthcare International, Inc. 55Copyright © 2012 All Rights Reserved
  56. 56. Redetermination Request for redetermination may be filled on Form CMS-20027 available at http://www.cms.hhs.gov/CMSForms/C MSForms/list.asp#TopOfPage Harmony Healthcare International, Inc. 56Copyright © 2012 All Rights Reserved
  57. 57. Redetermination Requests not made on Form CMS-20027 must include: Beneficiary name Medicare Health Insurance Claim (HIC) number Specific service and/or items(s) for which a redetermination is being requested. Specific date(s) of service Harmony Healthcare International, Inc. 57Copyright © 2012 All Rights Reserved
  58. 58. Redetermination Requests not made on Form CMS-20027 must include Name and signature of the party or the representative of the party (Usually the administrator of the building) The name and address of the facility Harmony Healthcare International, Inc. 58Copyright © 2012 All Rights Reserved
  59. 59. Redetermination Include an appeal letter that outlines the argument for coverage Brief explanation of the hospitalization (if one occurred) Past medical history Status of patient on admission List of the skilled nursing services provided to the patient Harmony Healthcare International, Inc. 59Copyright © 2012 All Rights Reserved
  60. 60. Redetermination Appeal Letter An explanation of skilled therapy services provided to the patient Medicare guidelines used in the skilled care decision making process, if applicable Harmony Healthcare International, Inc. 60Copyright © 2012 All Rights Reserved
  61. 61. Redetermination Any additional supporting documentation not submitted during the Help letter phase from the medical record should be submitted along with the redetermination request Highlight Add sticky tabs The redetermination request should be sent to the contractor that issued the initial determination Harmony Healthcare International, Inc. 61Copyright © 2012 All Rights Reserved
  62. 62. Redetermination Contractors will generally issue a decision within 60 days of receipt of redetermination request in the form of : A letter A Medicare Redetermination Notice (MRN) Revised remittance advice Harmony Healthcare International, Inc. 62Copyright © 2012 All Rights Reserved
  63. 63. Reconsideration If the request for redetermination results in a denial, a reconsideration can be requested A QIC will conduct the reconsideration request The QIC reconsideration process allows for an independent review of medical necessity by a panel of physicians or other health-care professions A minimum monetary threshold is not required to request a reconsideration Harmony Healthcare International, Inc. 63Copyright © 2012 All Rights Reserved
  64. 64. Reconsideration A written reconsideration request must be filed within 180 days of receipt of the redetermination Instructions are provided on the Medicare Redetermination Notice (MRN) A Request for reconsideration may be made on Form CMS-20033. This form will be mailed with the MRN Harmony Healthcare International, Inc. 64Copyright © 2012 All Rights Reserved
  65. 65. Reconsideration If Form 20033 is not used, request must contain: Beneficiary name Medicare Health Insurance Claim (HIC) number Specific service(s) and/or item(s) for which the reconsideration is requested Specific date(s) of service Harmony Healthcare International, Inc. 65Copyright © 2012 All Rights Reserved
  66. 66. Reconsideration Documents to include Name and signature of the party or the representative of the party (usually the administrator of the building) Name of the contractor that made the determination Name and address of the facility Harmony Healthcare International, Inc. 66Copyright © 2012 All Rights Reserved
  67. 67. Reconsideration Include a letter outlining the argument for payment Brief explanation of the hospitalization (if one occurred) Past medical history Status of patient on admission List of skilled nursing services provided to patient Explanation of skilled therapy services provided Medicare guidelines used in skilled care decision- making process, if applicable Harmony Healthcare International, Inc. 67Copyright © 2012 All Rights Reserved
  68. 68. Reconsideration The request should clearly explain why the facility disagrees with the redetermination A copy of the MRN, and any other supportive documentation, should be sent with the reconsideration request to the QIC identified in the MRN Harmony Healthcare International, Inc. 68Copyright © 2012 All Rights Reserved
  69. 69. Reconsideration If facility submits documentation after the reconsideration request has been filed, the QIC can extend the time they have to make their decision Additionally, any evidence noted in the redetermination as missing and any other evidence relevant to the appeal, must be submitted prior to the issuance of the reconsideration decision Harmony Healthcare International, Inc. 69Copyright © 2012 All Rights Reserved
  70. 70. Reconsideration Evidence not submitted at the reconsideration level may be excluded from consideration as subsequent levels of appeal unless you show good cause for submitting the evidence late Harmony Healthcare International, Inc. 70Copyright © 2012 All Rights Reserved
  71. 71. Reconsideration Reconsiderations are conducted on-the- record; and in most cases, the QIC will send its decision to all parties within 60 days of receipt of the request for reconsideration The decision will contain detailed info on further appeal rights if the decision is not fully favorable Harmony Healthcare International, Inc. 71Copyright © 2012 All Rights Reserved
  72. 72. Reconsideration If the QIC cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to an ALJ Harmony Healthcare International, Inc. 72Copyright © 2012 All Rights Reserved
  73. 73. Administrative Law Judge (ALJ) Hearings Harmony Healthcare International, Inc. 73Copyright © 2012 All Rights Reserved
  74. 74. ALJ Overview After the redetermination and reconsideration process, if at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration The facility must send a notice of the ALJ hearing request to the QIC on the hearing request form or in the written request Harmony Healthcare International, Inc. 74Copyright © 2012 All Rights Reserved
  75. 75. ALJ Overview A letter to request the ALJ hearing should simply highlight the most pertinent reasons justifying payment Harmony Healthcare International, Inc. 75Copyright © 2012 All Rights Reserved
  76. 76. ALJ Overview ALJ hearings are generally held by video-teleconference (VTC) or by telephone If the facility prefers not to have a VTC or telephone hearing, they may ask for an in-person hearing, but they must demonstrate the necessity for an in- person hearing Harmony Healthcare International, Inc. 76Copyright © 2012 All Rights Reserved
  77. 77. ALJ Overview The ALJ will determine whether an in- person hearing is warranted on a case-by- case basis Facilities may also ask the ALJ to make a decision without a hearing (on-the- record). CMS or its contractors may participate in an ALJ hearing, but they must provide notice to the ALJ and all parties of the hearing Harmony Healthcare International, Inc. 77Copyright © 2012 All Rights Reserved
  78. 78. ALJ Overview ALJ will generally issue a decision within 90 days of receipt of the hearing request The timeframe may be extended for a variety of reasons including, but not limited to: The case being escalated from the reconsideration level The submission of additional evidence not included with the hearing request The request for an in-person hearing The facility’s failure to send notice of the hearing request to other parties and The initiation of discovery if CMS is a party Harmony Healthcare International, Inc. 78Copyright © 2012 All Rights Reserved
  79. 79. ALJ Overview If the ALJ does not issue a decision within the applicable timeframe, you may ask the ALJ to escalate the case to the Appeals Council level Harmony Healthcare International, Inc. 79Copyright © 2012 All Rights Reserved
  80. 80. ALJ Hearing Preparation Harmony Healthcare International, Inc. 80Copyright © 2012 All Rights Reserved
  81. 81. ALJ Hearing Preparation Appeal Process Discuss and study CMS Guidelines Discuss type of ALJ hearing (video, phone, in person) to anticipate the format Goals of the Hearing Inform the Judge of skilled services Get the claim paid Harmony Healthcare International, Inc. 81Copyright © 2012 All Rights Reserved
  82. 82. ALJ Hearing Preparation Team Preparation Medical record review Outline of speaking points Select a point person for the hearing Team input Harmony Healthcare International, Inc. 82Copyright © 2012 All Rights Reserved
  83. 83. ALJ Hearing Hearing Process Prepare the facility designated hearing room for video or phone hearings Judge’s assistant will initiate the phone contact (test phone lines and speakers) Introductions Statement by facility Offer to fax any pertinent documents discussed during the hearing Harmony Healthcare International, Inc. 83Copyright © 2012 All Rights Reserved
  84. 84. ALJ Hearing Organize documentation Keep pertinent notes or forms at your finger tips Number the pages for reference Have the staff that worked with patient on the call Speak respectfully, clearly, slowly Provide a concise summary Harmony Healthcare International, Inc. 84Copyright © 2012 All Rights Reserved
  85. 85. ALJ Hearing Be prepared to answer questions prepared by the Judge Why did the patient require skilled therapy when they were hospitalized for a UTI? Where does the medical record state that continued therapy services were necessary after the initial date in question? Explain why skilled care continued although the notes indicate the patient did not have an exacerbation of medical condition? Harmony Healthcare International, Inc. 85Copyright © 2012 All Rights Reserved
  86. 86. ALJ Hearing Be prepared to answer questions asked by the Judge When did the patient get discharged from therapy services? Why do the daily nursing notes state the patient was ambulating ad lib, yet physical therapy continued to provide skilled treatment? Harmony Healthcare International, Inc. 86Copyright © 2012 All Rights Reserved
  87. 87. Strategies for Providers Provide clinically appropriate care Document Medical necessity Deficits Outcomes Meet technical requirements Review entire medical record Respond to ADRs timely Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87
  88. 88. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 www.Harmony-Healthcare.com EBovee@Harmony-Healthcare.com Harmony Healthcare International, Inc. 8888Copyright © 2013 All Rights Reserved
  89. 89. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc. 89Copyright © 2013 All Rights Reserved
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