TIPS FOR DEALING WITH ADRs, PROBE EDITS, AND THE MEDICARE APPEALS PROCESS Key Pints: The Centers fr Medicare & Medicaid Services ("CMS") and its cntractrs have brad ability t perfrm pre-payment and pst-payment medical reviews f hspice claims. Hspices mst cmmnly find themselves dealing with pre-payment medical reviews thrugh the Additinal Dcument Request r Additinal Develpment Request ("ADR") prcess initiated by their Fiscal Intermediary ( FI ) r Medicare Administrative Cntractr ( MAC ). Typically, these ADRs relate t a particular prbe r edit cnducted by the Intermediary. The prbe r edit may be service-specific (e.g. nn-cancer length f stay, general inpatient care, etc.), prvider-specific, beneficiary-specific r diagnsis driven. If claim payment is denied by the Intermediary after its ADR review (initial review determinatin), the hspice may chse t appeal that denial thrugh the Medicare appeals prcess. The steps in the appeals prcess are: Redeterminatin (reviewed by the Fiscal Intermediary) The appeal is due within 120 days f receipt f denial. The Intermediary must issue a decisin within 60 days f receiving the appeal. Details abut this level f review: This is nly a paper review. There is n pprtunity t discuss the case with the decisin-maker. While it is a step in the prcess, hspices may nt receive a payment reversal at this level f review. Recnsideratin (reviewed by a Qualified Independent Cntractr ("QIC )) The appeal is due within 180 days f receipt f redeterminatin decisin. 1 Page
This is the last appeal step that new evidence can autmatically be included as part f the review request. The QIC must generally issue a decisin within 60 days f receiving the appeal. All written evidence must be submitted at this level. Details abut this level f review: This is nly a paper review. There is n pprtunity t discuss the case with the decisin-maker. While it is a step in the prcess, hspices may nt receive a payment reversal at this level f review. Administrative Law Judge ("ALJ") The appeal is due within 60 days f receipt f recnsideratin decisin. The ALJ must generally issue a decisin within 90 days f receiving a hearing request. Details abut this level f review: This is the first pprtunity t have a discussin with a decisinmaker abut the case. The Office f Medicare Hearings and Appeals (OMHA) will schedule a telephne appeal. Hspices may chse a telephne appeal r a vide telecnference (VTC). Success may be mre likely if the ALJ can see the advcates fr the hspice prgram. The ALJ Request Frm des nt cntain a checkbx fr a VTC request. Yu will have t write this in and remind the administrative assistant wh calls t schedule a hearing that this is the type f hearing yu desire. At the hearing, hspices may chse t have medical directrs and nurses available t testify. The medical directr is particularly imprtant if the clinical eligibility f a patient is at issue. Administrative Law Judges have limited medical infrmatin and are always very happy t hear frm dctrs and nurses regarding clinical infrmatin. Hspices are t submit all written evidence at the Recnsideratin level. Hwever, they may submit additinal written evidence t the ALJ as lng as the ALJ finds gd cause fr the late submissin. Furthermre, even if the ALJ rejects the additinal written evidence, the hspice is nt precluded frm discussing the cntents f the additinal evidence at the hearing, and the ALJ may permit the hspice t read the additinal evidence int the recrd. 2 Page
The hspice shuld apprach the ALJ hearings as an pprtunity t educate. Sme judges will knw relatively little abut hspice law r plicy, s hspices shuld apprach the hearing with the mindset that they will be educating the judge. Medicare Appeals Cuncil * The appeal is due within 60 days f receiving the ALJ's decisin. The Medicare Appeals Cuncil must issue decisin within 90 days f receiving the request fr review. Details abut this level f review: This is generally a paper review. The Medicare Appeals Cuncil has the authrity t g back and review all claims again, including a re-review f claims that have been decided at the ALJ level in certain circumstances. The Medicare Appeals Cuncil generally fcuses its review n an ALJ decisin where the ALJ misapplies the law r the facts f the case; in these cases, the hspice shuld appeal t the Medicare Appeals Cuncil. Federal District Curt* The appeal is due within 60 days f receiving the Medicare Appeal Cuncil's decisin. (* Nte that hspices d nt typically appeal standard claim denial cases t the Medicare Appeals Cuncil r t Federal District Curt due t limitatins n appeals at these levels.) Tips and steps belw will help a hspice minimize the disruptin created by ADRs, and put the hspice in the best psitin t respnd effectively t the ADRs and mve ff the prbe r edit as sn as pssible. In additin, when appealing a payment denial, the strategies and suggestins belw will give the hspice the best chance f verturning the denial. Tips fr Dealing With ADRs and Prbe Edits Rutinely mnitr the Fiscal Intermediary Standard System (FISS) claims inquiry system t determine ADR requests and track ADR respnses. T ensure timely ntificatin f ADR requests, hspices shuld regularly check the FISS system because the timeframe fr respnse is nly 45 days. The FI/MAC may nt cmmunicate the utcme f the ADR by standard mail, s the prvider will need t cntinue mnitring the claims status specific t the patient. The hspice shuld als track the ADR requests and respnses n a spreadsheet r grid that includes applicable deadlines fr respnse. This nt nly helps the hspice keep track f the status f ADR respnses, but will be useful if the hspice chses t appeal any claims that are denied as part f a 3 Page
prbe. Check the system fr ADR claims t cnfirm receipt f yur medical recrds in respnse t the ADR. This cnfirmatin step is als available fr appeals sent t the QIC. Track yur appeals. If yu have nt received a respnse t an appeal within 60 days f submissin, begin calling the FI/MAC and/r QIC bdies. Yu may be tld that 1) Claim is nt in the system, even thugh yu have the mailing tracking infrmatin and knw it was delivered. (Knwing this allws time t resubmit.) r 2) N claim fund. Many appeals can be salvaged by clsely tracking status at the back end as well as at the frnt end. If a hspice has a recnsideratin appeal with MAXIMUS Federal Services, it can track the appeal at http://www.q2a.cm/q2a/q2a.nsf/ Ask t reduce the number f claims in the requested sample, if applicable. In prvider-specific prbes, the Fiscal Intermediary generally requests t review a set number f claims, ften between 20 and 40. Fr hspices with a small census, it might take the Intermediary several mnths t be able t gather enugh claims t cmplete the prbe, and the hspice wuld be faced with severe cash flw issues while the claims are caught in the prbe. A hspice in this situatin shuld ask the Intermediary t reduce the number f claims pulled in the prbe t a mre reasnable number based n the hspice's census. Cntinue t bill claims while in a prbe. Hspices smetimes make the mistake f ceasing billing when in a prbe. Hwever, this will simply prlng the prbe, because as discussed abve the Intermediary will need t pull billed claims in rder t cmplete its prbe. The irregular billing patterns may als raise additinal questins with the Intermediary. Submit a cver letter with ADR respnses. By submitting a cver letter highlighting the evidence that supprts patient eligibility, the hspice stands a better chance f aviding payment denials and targeted medical review. The cver letter shuld be written persuasively and cncisely (apprximately tw pages) t make the hspice's case fr patient eligibility during the claim perid at issue and pint t dcumentatin that supprts the hspice's psitin. As apprpriate, refer t r use the language f the CPs, LCDs, published articles describing current best practice, and ther dcuments in describing yur ratinale and decisins. The status f the patient (alive r deceased) shuld be included n the cver letter with each level f appeal. Patient status des change thrughut the prcess. Use a highlighter and highlight key infrmatin in the submitted medical recrd (i.e., assessments, clinical ntes, etc.) where the dcumentatin helps supprt the hspice s psitin. It makes the medical recrd a much quicker read fr the medical reviewer. Include schlarly articles abut the disease that supprts a patient s eligibility, especially if yu are dealing with an unusual diagnsis and dcument in yur letter hw the patient in questin cmpares t the article. LCD criteria are quite utdated in several disease specific grupings, and mre recent publicatins abut a specific diagnsis r interventin are imprtant evidence. Cnsider requesting an educatinal call. If the hspice receives a significant number f denials as part f a prbe, the hspice may request an educatinal call between the Intermediary and hspice staff. These calls are an pprtunity fr the hspice t ask 4 Page
questins and t hear what intermediaries lk fr in reviewing ADR dcumentatin; the calls als signal t the Intermediary that the hspice is making a gd faith effrt t imprve its perfrmance and is taking this prcess seriusly. Include dcumentatin frm ther claim perids, if helpful. The terminal cnditin f a hspice patient will ccasinally plateau, r even briefly imprve, during a mnth. This des nt mean that the patient is nt terminally ill, hwever. In this case, it is ften helpful t prvide dcumentatin frm claim perids utside thse requested n ADRs t shw the trajectry f the patient's disease, alng with a carefully crafted cver letter explaining the infrmatin and its relevance t the ADR perid. Include supprting dcumentatin frm attending physician visits, hspitalizatins, and ther dcuments that augment yur appeal. Cpy the recrds. Make a cpy f the patient s recrds. Number the cpy using sme srt f prefix that is specific t that patient, fr example, using the patient s initials and the page number. The prcess recmmended is t make ne cpy f the riginal file, put the numbering in place n each page (right hand bttm crner is standard), then make a cpy f the numbered set t send t the Intermediary and keep an exact cpy set fr the files. This system enables the prvider (and Intermediary) t realize if a page is missing, and it is easier thrughut the appeals prcess if everyne can reference the same page. If additinal dcumentatin is submitted at the QIC level, the numbering shuld cntinue frm the first submissin as ppsed t starting again. Nte that the ALJ may re-rder the recrd and will number the pages f the recrd nce the appeal reaches the ALJ. Hspices shuld request a cmplete cpy f the case file at the ALJ appeal. Send each ADR respnse separately. When hspices package ADR respnses tgether, the cmbined respnses will ccasinally be misplaced by the Intermediary. Althugh it is a little mre wrk frm an administrative perspective, it is always safest t send each ADR respnse separately, with a separate cver letter. Hspices shuld als cnsider sending the packages via vernight delivery r ther means by which timely receipt can be assured and tracked. Be sure the crrect address and mail cde are included as well as the name and cntact infrmatin f ne knwledgeable persn at yur hspice fr the Intermediary reviewer t reach if necessary. Never send riginal medical recrds and always keep a cpy f the ADR respnse. Hspices shuld send cpies f the medical recrds requested in the ADR as well as thse additinal dcuments that the hspice believes are relevant (as discussed abve). Original recrds shuld always be retained by the hspice. It is imprtant fr the hspice t retain an exact cpy f the infrmatin prvided t the Intermediary in respnse t an ADR. If the claim is denied by the Intermediary and the hspice decides t appeal the denial, the hspice can use the ADR respnse as the basis fr its appeal t the Intermediary. Knw yur Intermediary and understand the prbe. Each Intermediary treats ADRs slightly differently. It is imprtant t knw the standards that yur Intermediary has set when a hspice is placed n targeted medical review. Understanding the type f prbe that yu are in will be imprtant as yu respnd t the ADRs. If yu are unsure, cntact yur Intermediary. Dcument! The mst imprtant strategy fr successfully respnding t an ADR is a practive ne clearly and carefully dcument the patient's cnditin and the services 5 Page
prvided s that the dcumentatin submitted with an ADR respnse leaves n dubt f the patient's hspice eligibility. Lcal Cverage Determinatins ("LCDs"), while nt the legal standard fr hspice eligibility, are strictly fllwed by reviewers evaluating ADR respnses. As a result, a hspice shuld integrate the LCD int its admissin, certificatin and IDT meeting prcesses, and educate nursing staff n LCD elements such that the patient's clinical recrd will shw that the patient's cnditin meets the LCD whenever pssible. If yu are having truble with dcumentatin, cnsider hiring a hspice cnsultant t help staff with effective strategies t imprve dcumentatin. Tips fr Dealing With The Medicare Appeals Prcess Draft a persuasive cver letter. Just as a cver letter is imprtant in a hspice's respnse t an ADR, the cver letter becmes even mre imprtant when submitting a Medicare appeal. The hspice can mdify the cver letter it submitted in respnse t the ADR t address the specific issues raised by the Intermediary in issuing its claim denial. Develping an effective letter at the redeterminatin level increases the hspice's chance f success early in the appeals prcess. Furthermre, the same letter can be easily mdified t use fr the recnsideratin request and the request fr an ALJ hearing as well. ALJs have als been requesting that appellants file "written statements." An effective cver letter can be used t satisfy the written statement requirement. Understand yur weaknesses. Hspices shuld bjectively evaluate whether t pursue an appeal f a claim denial based n the patient's cnditin and the hspice dcumentatin fr that claim perid. Even if weaknesses in a case are nt addressed in the cver letter t the Intermediary r QIC, the hspice will need t be prepared t respnd t the weaknesses in a case if the ALJ raises them at a hearing. Stay rganized. A tracking tl is imprtant t allw the hspice t keep n tp f appeal deadlines. Develp a system t mnitr appraching deadlines t ensure that yur hspice des nt miss deadlines and the pprtunity t appeal. Fr purpses f cmplying with filing deadlines, nte that in general, it will be presumed that the hspice receives ntificatin f a denial 5 days after the date f the denial, unless there is evidence t the cntrary, and appeal requests will be cnsidered filed n the date they are received by the apprpriate entity. Cnsider requesting cnslidatin f appeals fr multiple claim perids. If a hspice has multiple payment denials fr the same beneficiary, cnsider whether t request that the Intermediary, QIC r ALJ (depending n the level f appeal) cnslidate the denials int ne appeal request. This can have the benefit f reducing sme administrative burdens f appealing the claims separately, and allws the hspice t mre effectively shw the patient's disease trajectry ver a perid f time. Claims can nly be cnslidated if they are at the same level f appeal, and with the apprval f the appeal bdy. Cnsider hiring an utside clinical cnsultant. If needed, utside clinical cnsultants can bring a vice f bjectivity t claims that were denied fr clinical reasns. Clinical cnsultants can write a letter in supprt f eligibility if the hspice appeals a denial, but, just as imprtantly, they can let the hspice knw when they believe that the dcumentatin des nt bjectively supprt eligibility. They can als wrk with a hspice n prcess and dcumentatin imprvements that culd reduce future claim denials. 6 Page
Addressing LCDs. Fr the purpses f Medicare appeals, there are several imprtant things t remember abut the LCDs. First, the LCDs are nt the same thing as the legal requirements fr hspice eligibility. QICs, ALJs and the Appeals Cuncil are nt bund by LCDs, but they will give them substantial deference if they are applicable. Secnd, the LCDs are nt always precise; sme f the standards may be subject t interpretatin r may be based n utdated infrmatin. Finally, mst f the LCDs include disclaimers that patients may still be eligible fr hspice care, even if they d nt meet all f the elements f the LCD, if there are ther reliable indicatrs f a terminal cnditin. In general, the cver letter shuld address the LCDs, and shuld discuss why the patient met the LCD, r, if the patient did nt meet every element, what ther factrs supprted a terminal prgnsis. A hspice shuld nt feel that it cannt appeal a case because the patient did nt meet every element f an LCD. EVERY LCD sectin that applies t the patient and their diagnsis shuld be addressed. Make it easy fr the decisin-maker t find in yur favr. All f the cntractrs are facing a backlg f cases, and it is pssible that the key facts in yur case will get lst in the shuffle if yu d nt pint them ut clearly t the reviewer. Make it easy fr the reviewer by rganizing the medical recrd in a cherent fashin and making key dcumentatin easy t find. Denials can smetimes result frm the cntractr failing t see a dcument in the medical recrd. Attaching key dcumentatin as a separate exhibit, r pinting ut where it can be fund in the medical recrd, can help minimize these issues. Learn frm the prcess. If a claim payment was denied because the dcumentatin did nt supprt eligibility, try t understand what part f the dcumentatin was perceived t be insufficient and develp strategies t address the issue. If yu find yurself subject t a number f technical denials, fr example, reevaluate yur certificatin prcesses and ntice f electin frms. Netwrk with ther hspices wh are served by the same FI/MAC t share the experience s that yu can develp a prcess that wrks fr yur rganizatin. 7 Page