Health Care Collector - Kluwer Law International

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PAGE6 AUGUST 2010 insurance) and Part B (medical insurance) coverage to that beneficiary. MA plans must cover all the services that traditional Medicare covers except hospice care. The lure for many beneficiaries is the “advantage” that MA plans can offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Almost all MA plans include Medicare prescription drug coverage. Because patients pay one monthly premium (in addition to their Part B premium), they often view the program as a simplified alternative requiring less paperwork. But MA plans bring an element of risk to the marketplace. These plans often seek to balance their risk by passing extra costs on to the provider and indirectly to the patient. Unlike traditional Medicare, MA plans add additional levels of authorizations and medical records requests that delay payment. In one survey, some providers reported that they can expect payment from Medicare within 25 days while MA plans take over 50 days to pay the same claim. While MA contractors will see cuts in premium levels from CMS, MA plans will remain a choice for beneficiaries under health care reform. Regardless of premium amounts, the contractors cannot cut core benefits to the beneficiaries. The risk for providers is that the MA plans will continue to balance their budgets by taking their “savings” from providers. Beneficiary Choice and Consequence Patients often think that an MA plan will administer their benefits while simplifying the paperwork. When patients choose an MA plan, they don’t factor into their decision the restrictive policies that exist under these plans. But CMS makes it very clear in their official beneficiary handbook, Medicare & You 2010 , when they state: Medicare pays a fixed amount for your care every month. These companies follow the rules set by Medicare. However, each Medicare Advantage Plan can charge different out of pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan). . . . If you get health care outside the plan’s network, you may have to pay the full cost. . . . Make sure you understand how a plan works before you join. Not all plans work the same way, so before you join, find out the plan’s rules, what your costs will be, and whether the plan will meet your needs. . . . It is important that you follow the plan’s rules, like getting prior approval for certain services when needed. . . . It is questionable how many patients have conducted a thorough review of their MA plan, and whether they fully understand that they have given up the flexibility of a full choice of providers. For more mobile beneficiaries, they may not realize the financial impact of seeking care outside their service area. This is often a big shock to patients who travel or who split their time between summer and winter homes. While emergent services are covered, the routine care is not. It falls upon the provider to inform patients that they may not be covered for the services they need. MA plans often seek to balance their risk by passing extra costs on to the provider and indirectly to the patient. When patients are unprepared for the additional responsibility they take on when they sign up for an MA plan, the provider must take an active role in advocating for their patients so that their patients get the most out of their benefits. Part of this is about educating the patient. If the patient was not fully informed about the risks and limits of the MA plan, the patient can request to un-enroll in the plan. In the Medicare & You 2010 handbook there are instructions for patients who are already in MA plans who need to switch to traditional Medicare. Risk Points Indeed, gaps in provider documentation have promoted the image that MA plan savings come from preventing what they deem to be unnecessary care. In most cases, despite these documentation gaps, the care follows the standard courses of treatment. However, much of the payer savings are recouped in other risk points. The provider is vulnerable in a number of areas and these are the very points that the MA plan claims processor exploits to gain profits. Some examples of these risk points are: • The point of service. Providers have difficulty identifying MA plan coverage vs. Medicare coverage, authorization requirements, notification requirements, and care management requirements. (Utilization review nurses and doctor intervention is needed to prevent gaps.) HEALTH CARE COLLECTOR
PAGE7 Medicare Advantage Appeal Process Flowchart STANDARD EXPEDITED Pre-service: 14-day time limit Payment: 60-day time limit Pre-service: 72-hour time limit Payment requests cannot be expedited 60 days to file 60 days to file Health Plan Reconsideration Pre-service: 30-day time limit Payment: 60-day time limit First-Level Appeal Health Plan Reconsideration 72-hour time limit Payment requests cannot be expedited 60 days to file Automatic IRE Review 60 days to file (if plan upholds denial) IRE Reconsideration Pre-service: 30-day time limit Payment: 60-day time limit Second-Level Appeal IRE Reconsideration 72-hour time limit Payment requests cannot be expedited 60 days to file Third-Level Appeal Administrative Law Judge Office of Medicare Hearings and Appeals AIC over $120* No statutory time limit for processing 60 days to file Fourth-Level Appeal Medicare Appeals Council No statutory time limit for processing 60 days to file Fifth-Appeal Level Federal District Court AIC over $1,220* AIC = Amount in Controversy ALJ = Administrative Law Judge IRE = Independent Review Entity *The AIC requirement for an ALJ hearing in federal court is adjusted annually in accordance with the medical care component of the Consumer Price Index. • The billing rules process. MA payer staff has fragmented understanding of uniform billing (UB) rules and codes, and, thus, often falsely deny claims when they misread or fail to properly interpret the claim information provided by the UB codes. • Demands for additional information or records. MA payers request records and conduct medical review at double the rate of Medicare. MA payers are also known to reject claims based upon a “technical denial” at excessive rates compared HEALTH CARE COLLECTOR AUGUST 2010
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