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PAGE8 AUGUST 2010 to traditional Medicare. These technical denials include medical necessity, DRG assignment, length of stay denials, pricing reviews, etc. MA Appeals As if CMS anticipated the potential abuse of the claims payment process, a solid appeal structure was established to offer recourse to damaged providers and concerned beneficiaries. Providers and patients should view the MA appeals process as a way to hold MA plans accountable, ensuring that good payers are rewarded for their investment in meeting expected standards and bad payers are driven out of the marketplace. Unless this occurs, the bad payers will unfairly benefit from their poor compliance with billing rules, enabling them to reap profits, even reduce premiums, to gain more market share. The appeals process is the best way to ensure fair trade practices among the MA payers. 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. Providers may not be using the opportunity to appeal MA claim denials as extensively as they might. At a recent appeals workshop conducted by the American Association of Healthcare Administrative Management (AAHAM), Medicare consultant Diana Smithson outlined the options for appealing traditional Medicare and Medicaid Advantage plans. (The appeals process for traditional or original Medicare in discussed in the July 2010 issue of Health Care Collector. ) 1 As Smithson outlined the steps to appeal claim denials and other payment barriers, I realized that the majority of the audience had not used their appeal options with Medicare or the MA plans. I asked my fellow audience members how many had successfully filed MA appeals. One audience member, Seattle’s Northwest Hospital Business Office Director, Janet Walthew, reported that she had a great appeal success rate. One reason for Janet’s success is her confidence in the appeals process, in part because she previously worked for an MA plan and she has an insider’s view of the process. She also understands the importance that CMS places on the appeals process to ensure balance in the marketplace. Beneficiary Appeals Medicare beneficiaries have appeal rights, too. When a beneficiary disagrees with a coverage or payment decision made by an MA plan, the beneficiary can appeal for a variety of reasons, which are explained in the Medicare & You 2010 handbook. In addition to fee-for-service denials, beneficiaries can also file appeals for: • Organization determinations to not authorize services. This can include, but is not limited to: — Specialist referrals; — Service denials; and — Refusal to authorize durable medical equipment (DME); • Out-of-area services that the MA plan does not consider urgent or emergent; • Non-authorized, out-of-network services that the MA plan does not consider emergent; and • Out-of-area dialysis services. CMS also provides recourse for patients who need assistance with an appeal. While contracted providers have no appeal rights, the appeal options for the beneficiary could include appointing the provider as a representative. Providers can secure a signature from the patient authorizing them to take their place in the appeal. Expedited Review A patient can also request a “fast appeal” under the Expedited Review process. If the patient is receiving Medicare services from a hospital, skilled nursing facility, home health agency, rehab facility, or hospice, and the patient thinks his or her Medicarecovered services are ending or ending too soon, the patient has the right to an immediate appeal response under the Expedited Review, process. With an Expedited Review, an independent reviewer, the Quality Improvement Organization (QIO), will decide if the services should continue. Editor’s Note: For an overview of both the MA Standard Appeal and the Expedited Appeal, see the Medicare Advantage Appeal Process Flowchart. Provider Appeals Providers contracted with an MA plan have no appeal rights, as mentioned, but non-contracted HEALTH CARE COLLECTOR
PAGE9 providers may appeal. However, they must agree to waive payment if the appeal upholds the original decision. Providers start by asking for a “reopening.” Requested by the provider, the appeal can be based on a factor outside the provider’s controls that changes the perspective of the claim, such as late medical documentation or clerical errors. Appeals must be made within a year unless the provider can prove “good cause” for delay. Special Appeals Under LCD and NCD Local coverage decisions (LCDs) made by the Medicare administrative contractor can result in coverage or non-coverage in different localities. A littleknown option built into the LCD as well as national coverage determination (NCD) rules is that CMS allows for exceptions to the decisions that adversely impact patients in one US geographic region vs. another. For example, some procedures that are excluded for West Coast residents under LCDs are approved under East Coast LCDs. Thus, CMS allows for a patient to appeal this limitation. Appeal rights only apply to beneficiaries and are filed when an LCD or NCD is involved and the patient is adversely affected in accessing care. Indeed, there may be some common ground in the LCD and the recourse under expedited appeal cases. While appeals may be made to the CMS Regional or Central Office, it is acceptable to ask for congressional intervention in those cases where variances in local jurisdiction impact a beneficiary and his or her care. In the next Biller’s Corner, we will explore the anatomy of a Medicare Advantage appeal by examining some case studies and outcomes involving Seattle’s Northwest Hospital. Its Business Office Director, Janet Walthew, shares her tips for providers. ■ Note 1. Volume 24, no. 2, Aspen Publishers, Inc. About the Author Judy I. Veazie, CPAM, has over 30 years of experience in the health care industry. She has consulted extensively on revenue cycle management; she is an instructor in HIM and medical practice management, and a frequent speaker to professional organizations, as well as former editor of the Health Care Biller newsletter (Aspen Publishers, Inc.). Contact her at judyveazie@yahoo.com. Helping Patients Understand Health Care Costs Helen Osborne, M.Ed., OTR/L W illiam Shrank, MD, MSHS, knows a lot about health care costs, especially the copays (out-of-pocket expenses) that patients spend on prescription medications. Shrank is not only a practicing physician but also an instructor at Harvard Medical School and at the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women’s Hospital in Boston. As a researcher, Shrank looks at the big picture of health economics and studies how the cost of prescription medication affects physicians, pharmacists, and health care systems. And as a physician, he sees the more personal side of how out-of-pocket expenses can have an impact on a patient’s health. Shrank talks about a patient he is treating who has several chronic conditions. He has prescribed numerous medications for this patient but recently learned the patient does not always fill them. It turns out that the patient is on a fixed income and, despite having health insurance, must sometimes choose whether to pay for rent, food, or drugs. Shrank says that when faced with these choices, “drugs don’t always win.” The Value of Opportunity The situation Shrank describes is all too common in health care today. What is unusual is that Shrank and his patient talked about it. Once Shrank learned of the choices his patient had to make, he changed his patient’s prescriptions from nonpreferred drugs (with the highest copays) to less costly generic and preferred ones. While many providers agree it is important to talk about health care costs, they are not equally clear about whose job it is to do so. Shrank thinks that all health professionals can help. Below are suggestions he offers for ways to get started. Many of the HEALTH CARE COLLECTOR AUGUST 2010
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Health Care Collector - Kluwer Law International

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