Expedited Appeals Training Session July 2006

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Expedited Appeals Training SessionJuly 2006

• Donna McIvor, RN, BSN
• Lumetra
• Manager, Appeals

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Agenda

• Overview on Lumetra and UGS
• Expedited appeals process
• Notices
• Time frames and liability
• Physician review of appeals
• Q and A

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Lumetra Overview

• Lumetra was established 20 years ago as an
  independent, nonprofit organization.
• Lumetras work centers on measurably improving
  the quality, safety, and integrity of healthcare.
  
• Lumetra provides innovative services and
  solutions in the areas of quality improvement,
  medical review, health information technology,
  data analysis, and marketing and communications.
• Since 1984, Lumetra has been contracted by the
  Centers for Medicare Medicaid Services (CMS) to
  be the Medicare Quality Improvement Organization
  (QIO) for California.

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United Government Services (UGS) Overview

• Largest Part A claims processor in Medicare
• 32 million claims / year
• Seven states for SNF and outpatient
• 13 states for home health and hospice
• 50 states ( DC) for FQHC
• Largest dialysis facility claims processor
• Principal offices in Milwaukee, Wisconsin and
  Camarillo, California
• A division of Wellpoint, Inc.

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Objectives

• Describe Lumetra's role in working with
  patients, providers, and physicians to ensure
  appropriate implementation of the expedited
  appeals process that maintains patient quality of
  care while avoiding premature discharges or
  unnecessary continuation of stays.
• Demonstrate key steps in the expedited appeals
  process, including those addressing the
  physician's responsibility, and those involving
  delivery of proper patient notification.
• Identify how the Part A Payer interfaces in the
  expedited appeals process.

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What is Grijalva?

• A class action lawsuit brought by beneficiaries
  enrolled in Medicare Advantage (MA), a Medicare
  Managed Care program.
• As a result of the lawsuit, the Centers for
  Medicare Medicaid Services (CMS) agreed to
  establish new notices and appeals procedures when
  an MA plan terminates coverage of provider
  services.

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What Providers Are Affected?

• Home health agencies (HHAs)
• Skilled nursing facilities (SNFs)
• Comprehensive outpatient rehabilitation
  facilities (CORFs)
• Health plans

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Overview of Appeals Process

• Healthcare provider gives Medicare beneficiary a
  Termination/Discharge Notice.
• Beneficiary appeals to Lumetra.
• Lumetra contacts provider regarding appeal.
• Provider sends Detailed Notice and medical
  records to Lumetra.

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Appeals Process Continued

• Lumetra physician reviewer makes determination on
  appeal.
• Beneficiary has an option for a reconsideration.
• Reconsideration provided by Qualified Independent
  Contractors (QIC) for FFS and Lumetra for MA (for
  now).

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Discharge NoticeProviders Responsibility

• Timing of notice delivery
• Discharge Notice issued no later than two (2)
  visits or two (2) days before the proposed end of
  services.
• If the span of time between services exceeds two
  (2) days, the notice must be given no later than
  the next to the last time services are furnished.
• NOTE Only if services terminated not if
  reduced not for benefits exhaustion.

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Details of Discharge NoticeProviders
Responsibility

• Beneficiarys name and Medicare number
• Date coverage of service ends
• Type of coverage ending
• Name and telephone number of Lumetra
• Description of right to appeal
• Description of right to detailed information

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Notice Delivery

• Beneficiary signs notice.
• If beneficiary refuses to sign, annotate the
  notice to indicate the refusal.
• The date of the refusal is the date of receipt of
  the notice.

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How To Avoid Invalid Discharge Notices

• The discharge notice must be delivered at least
  two (2) days prior to the date of discharge.
• When delivering the notice, explain the appeals
  process to the beneficiary/representative.
• If the beneficiary is incompetent, and you reach
  the representative by phone, you must explain the
  appeals process, give Lumetras phone number to
  call and the deadline to call before noon the
  next day annotate the notice of these facts,
  sign date it and note that you have put this
  notice in regular mail on the same day copy it
  then mail it. This will be a valid delivery of
  the discharge notice.

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How To Avoid Invalid Discharge Notices

• If the Beneficiary is incompetent and you cannot
  reach the representative by phone annotate this
  on the discharge letter, sign, date, copy and
  then mail the same day by Certified Mail, copy
  the tracking slip, and fax to Lumetra a copy of
  this discharge notice and a copy of the certified
  mail tracking slip. This will be a valid notice.

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Provider Financial Liability

• The provider is liable for continued services
• until two calendar days after the beneficiary
  receives a valid notice
• or
• until the service termination date, whichever is
  later.

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Conditions for Appeal

• Medicare beneficiary may appeal if
• beneficiary disagrees with termination of service
  or discharge notice

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Medicare Beneficiarys Appeal Request

• The beneficiary (or representative) must call
  Lumetra and request an appeal by noon of the day
  prior to termination of service(s) or by noon of
  the next day after receiving the discharge notice.

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Providers ResponsibilityDetailed Explanation
Non Coverage

• This DENC is to provide a specific and detailed
  explanation as to why services are either no
  longer reasonable and necessary or are no longer
  covered. (DENC)
• This notice is to describe any applicable
  Medicare coverage rules, instruction, or other
  Medicare policy rules or information about how
  the beneficiary may obtain a copy of the Medicare
  policy.

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Providers ResponsibilityInformation to Lumetra

• After the beneficiary/representative has called
  for an appeal, and Lumetra calls you, the
  healthcare plan,you need to
• Fax to Lumetra all relevant clinical information,
  including a copy of the Discharge/Termination and
  Detailed Notices
• For expedited appeals, this information should be
  furnished no later than the close of business on
  the day Lumetra notifies the provider of the
  appeal (or expected by noon of the next day if
  Lumetra requests the records late in the
  afternoon).

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Responsibility of Lumetra Expedited Review

• Lumetra must determine whether termination of
  Medicare coverage is the correct decision within
  48 hours from receipt of an expedited appeal
  request or 24 hours after the medical records are
  received.

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Physician Review of Appeals

• All physician reviewers are board-certified and
  in active practice.
• They review the available medical record
  documentation.
• They must attempt to reach the patients
  attending physician (name and number received
  from provider) to hear his/her perspective on the
  appeal issue why the TMD feels discharge is
  appropriate.

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Physician Review of Appeals

• The physician reviewers are asked to address the
  following
• Why the patient was admitted?
• What services have been received and why?
• What level of care/services is the patient
  expected to need by the date of termination and
  why?
• Should the notice be upheld? Why/why not?

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Physician Review of Reconsiderations

• All Medicare Advantage reconsiderations are the
  responsibility of Lumetra
• Are reviewed by a physician reviewer NOT involved
  in the initial review
• Evaluate case anew, including reviewing any
  reason specified for reconsideration request

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Responsibility of Lumetra Determination

• Notify the beneficiary or representative,the
  healthcare plan the provider of Lumetras
  determination. The beneficiarys physician
  receives the letter.
• Initial notification is made by telephone.
• A written notification must follow.

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Medicare Beneficiary Reconsideration

• Only the beneficiary (or representative) may ask
  for a reconsideration (SNF). The Attending
  Physician or beneficiary may request for a stay
  in an acute facility.
• Lumetra determines MA reconsiderations (for now).

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Coverage of Provider Services

• If Lumetras decision is delayed because the
  healthcare plan/provider did not supply the
  necessary information or records in a timely
  manner, then the healthcare plan/provider is
  liable for costs of any additional days of
  coverage.

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Fiscal Intermediary (FI) Perspective

• UGS is collecting QIO expedited reviews to
  determine patterns, if any, of support or
  overturn.
• When initial notice of anticipated discharge-
  termination notices are filled out appropriately,
  with adequate clinical data, Lumetra has usually
  agreed with provider.
• If the QIO or QIC decision is unfavorable to
  provider, another notice can be delivered in a
  few days.

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QIO Key Learnings

• Discharge/Termination Notices must have a valid
  delivery.
• Detailed Notices must be included.
• Medical record documentation must be sufficient -
  physical and occupational therapy charting must
  be current and discharge planning or social
  services notes should be included.

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Key Learnings

• Expedited determinations are not required if
  there is a reduction but not termination in
  services or if Medicare benefits run out.
• Medical necessity remains key to continued
  coverage of services.

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CMS Expedited Appeals Web Page

• Visit the CMS Web site at http//www.cms.hhs.gov/B
  NI/ for information on
• The expedited appeals process
• Notices and instructions
• Frequently asked questions, including questions
  of which notices to use and when

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Q and A

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Lumetra Contact Information

• Donna McIvor, RN, BSN
• Manager, Appeals Helpline
• Phone [phone]
• E-mail Dmcivor_at_caqio.sdps.org
• Visit our Web site at www.lumetra.com