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Being More Appealing. Bobbi Buell ION October, 2008. AGENDA. Medicare Appeals Process The Appeal Cycle Assessment/ Analysis Information Gathering Appeal Drafting Follow Up Tools for Providers. PART A & PART B PROCESS (Non-Expedited). Beneficiary receives the service

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being more appealing

Being More Appealing

Bobbi Buell

ION

October, 2008

agenda
AGENDA
  • Medicare Appeals Process
  • The Appeal Cycle
    • Assessment/ Analysis
    • Information Gathering
    • Appeal Drafting
    • Follow Up
  • Tools for Providers
part a part b process non expedited
PART A & PART B PROCESS (Non-Expedited)
  • Beneficiary receives the service
  • Medicare contractor (fiscal intermediary or carrier) issues initial determination explaining whether Medicare will pay for a service already received.
  • Beneficiary has 120 days to request redetermination by contractor. Provider may also request redetermination
    • Appeals will be consolidated
    • Time frame may be extended for “good cause”
  • Contractor has 60 days to issue redetermination
part a part b appeals cont
PART A & PART B APPEALS (cont.)
  • If redetermination is unfavorable can request a

“reconsideration” by Qualified Independent

Contractors (QICs)

    • 120 days to request reconsideration
    • Beneficiary & provider appeals will be consolidated
    • Time may be extended for good cause
  • QIC must issue decision within 60 days.
    • Parties may request escalation to ALJ if time frame not met
  • 60 days to request review by ALJ
alj hearings
ALJ HEARINGS
  • Hearings conducted by Medicare ALJs in DHHS Office of Medicare Hearings and Appeals
  • ALJs are in 4 regional offices, not local offices
    • Cleveland, OH
    • Irvine, CA
    • Miami, FL
    • Arlington, VA
  • For Part A and Part B claims, ALJ must issue decision within 90 days – with exceptions
    • No time limit if request for in-person hearing granted
alj hearings cont
ALJ HEARINGS (cont.)

For ALJ hearings under Parts A, B, C & D

  • Amount of claim must be at least $110 in 2007
    • Subject to annual increase
    • Can aggregate certain claims
  • Hearings conducted by video teleconferencing (VTC) if available, or by telephone
    • ALJ assigned to case has discretion to grant request for in-person hearing
appeals process beyond the alj hearing
APPEALS PROCESS – BEYOND THE ALJ HEARING
  • If ALJ decision is unfavorable, have 60 days to request MAC review
    • MAC request requires specific statement of issues,
    • MAC reviews the record concerning only those issues, unless unrepresented beneficiary requests.
  • If MAC decision is unfavorable, have 60 days to request review in federal court
    • Must meet amount in controversy requirement
      • Amount may increase each year ($1130 in 2007)
calculating time frames
CALCULATING TIME FRAMES
  • Time frames are generally calculated from date of receipt of notice
  • 5 days added to notice date
  • Time frames sometimes extended for good cause, ex.
    • Serious illness
    • Death in family
    • Records destroyed by fire/flood, etc
    • Did not receive notice
    • Wrong information from contractor
    • Sent request in good faith but it did not arrive
medicare advantage appeals
MEDICARE ADVANTAGE APPEALS
  • “Organization determination” is initial determination regarding basic and optional benefits
    • Can be provided before or after services received
    • Issued within 14 days
  • May request expedited organization determination if delay could jeopardize life/health or ability to regain maximum function.
    • Plan must treat as expedited if requested by doctor
    • Issued within 72 hours
medicare advantage ma
MEDICARE ADVANTAGE (MA)
  • Request reconsideration w/i 60 days of notice of the organization determination.
  • Reconsideration decision issued within
    • 30 days for standard reconsideration.
    • 72 hours for expedited reconsideration.
  • Unfavorable reconsiderations automatically referred to independent review entity (IRE).
    • Time frame for decision set by contract, not regulation
  • Unfavorable IRE decisions may be appealed
    • to ALJ
    • to MAC
    • to Federal Court
medicare advantage ma1
MEDICARE ADVANTAGE (MA)
  • Fast-Track Appeals to Independent Review Entity (IRE) before services end for
    • Terminations of home health, SNF, CORF
    • Two-day advance notice
    • Request review by noon of day after receive notice
    • IRE issues decision by noon of day after day it receives appeal request
  • 60 days to request reconsideration by IRE
    • 14 days for IRE to act
medicare advantage grievance procedures
MEDICARE ADVANTAGE GRIEVANCE PROCEDURES
  • Grievance procedures to address complaints that are not organization determinations.
    • 60 after the event or incident to request grievance
    • Decision no later than 30 days of receipt of grievance.
    • 24 hours for grievance concerning denial of request for expedited review.
part d appeals process overview
PART D APPEALS PROCESS-OVERVIEW
  • Each drug plan must have an appeals process
    • Including process for expedited requests
  • A coverage determination is first step to get into the appeals process
    • Issued by the drug plan
    • An “exception” is a type of coverage determination
  • Next steps include
    • Redetermination by the drug plan
    • Reconsideration by the independent review entity (IRE)
    • Administrative law judge (ALJ) hearing
    • Medicare Appeals Council (MAC) review
    • Federal court
part d appeals process coverage determination
PART D APPEALS PROCESS – COVERAGE DETERMINATION
  • A coverage determination may be requested by
    • A beneficiary
    • A beneficiary’s appointed representative
    • Prescribing physician
  • Drug plan must issue coverage determination as expeditiously as enrollee’s health requires, but no later than
    • 72 hours standard request
      • Including when beneficiary already paid for drug
    • 24 hours if expedited- standard time frame jeopardize life/health of beneficiary or ability to regain maximum function.
exceptions a subset of coverage determination
EXCEPTIONS: A SUBSET OF COVERAGE DETERMINATION
  • An exception is a type of coverage determination and gets enrollee into the appeals process
  • Beneficiaries may request an exception
    • To cover non-formulary drugs
    • To waive utilization management requirements
    • To reduce cost sharing for formulary drug
      • No exception for specialty drugs or to reduce costs to tier for generic drugs
  • A doctor must submit a statement in support of the exception
part d appeals coverage determinations are not automatic
PART D APPEALS - COVERAGE DETERMINATIONS ARE NOT AUTOMATIC

A statement by the pharmacy (not by the Plan) that the Plan will not cover a requested drug is not a coverage determination

  • Enrollee who wants to appeal must contact drug plan to get a coverage determination
  • Drug plan must arrange with network pharmacies
    • To post generic notice telling enrollees to contact plan if they disagree with information provided by pharmacist or
    • To distribute generic notice
part d appeals process next steps
PART D APPEALS PROCESS –NEXT STEPS

If a coverage determination is unfavorable:

  • Redetermination by the drug plan.
    • Beneficiary has 60 days to file written request (plan may accept oral requests).
    • Plan must act within 7 days - standard
    • Plan must act within 72 hrs.- expedited
  • Then, Reconsideration by IRE
    • Beneficiary has 60 days to file written request
    • IRE must act w/i 7 days standard, 72 hrs. expedited
  • ALJ hearing
  • MAC review
  • Federal court
part d grievance process
PART D GRIEVANCE PROCESS
  • Each drug plan must have a separate grievance process to address issues that are not appeals
  • May be filed orally /in writing w/i 60 days
  • Plans must resolve grievances
    • w/i 30 days generally
    • w/i 24 hrs if arise from decision not to expedite coverage determination or redetermination
useful websites
USEFUL WEBSITES
  • www.medicare.gov
  • www.medicareadvocacy.org
  • www.healthassistancepartnership.org
  • www.nsclc.org
center for medicare advocacy inc

CENTER FOR MEDICARE ADVOCACY, INC.

_________________www.medicareadvocacy.org

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