Medicare Quality Improvement Organization QIO Reviews Under the Benefits Improvement and Protection

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Medicare Quality Improvement Organization
(QIO) Reviews Under the Benefits Improvement and
Protection Act 521 Presented by Alabama
Quality Assurance Foundation 2005
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Benefits Improvement and Protection Act (BIPA)
521

• Federal Register, Friday, November 26, 2004
• 42 CFR 405.1200-1206
• To locate http//www.gpoaccess.gov/fr
• Select Advanced (1994-2005)
• Select Volume 2004 FR, Vol. 69
• Select Section Final Rules Regulations
• Specific Date On 11/26/2004
• Search 42 CFR.405
• Click Submit
• Click Medicare Program Expedited Determination
  Procedures for Provider

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Benefits Improvement and Protection Act (BIPA)
521

• Section 521 of the Medicare, Medicaid and SCHIP
  Benefits Improvement Act of 2000 (BIPA), amended
  section 1869 of the SSA (the Act) to require
  significant changes to the Medicare appeals
  procedures.

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Benefits Improvement and Protection Act (BIPA)
521

• The Act required establishment of a process by
  which a beneficiary may obtain an expedited
  determination in response to the termination of
  provider services.

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Affected Health Care Providers

• Home Health Agencies (HHAs)
• Hospices
• Skilled Nursing Facilities (SNFs)
• Comprehensive Outpatient Rehabilitation
  Facilities (CORFs)

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Termination of Medicare-
Covered Services

• Discharge from a residential provider (ending of
  skilled services)
• Complete cessation of coverage at the end of a
  course of treatment

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Provider ResponsibilityMedicare
Beneficiarys Right

• Advance written notice of service terminations
• Before any termination of services, the provider
  must deliver a valid written notice to the
  beneficiary of the decision to terminate
  services.

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Provider ResponsibilityMedicare
Beneficiarys Right

• Termination does not include a reduction in
  services.
• Does not include the termination of one type of
  service by the provider if the beneficiary
  continues to receive other Medicare-covered
  services from the provider.

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Provider Responsibility Medicare Beneficiarys
Right

• The new expedited determination process at 69
  Fed. Reg. 69252 (Nov. 26, 2004) governs all
  terminations of previously covered HHA services.

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Provider Responsibility Timing of Notice
Delivery

• Issued not later than two calendar days before
  the proposed end of the services
• If services are fewer than two days in duration,
  the notice should be issued at the time of
  admission

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Provider Responsibility Timing of Notice
Delivery

• If, in a non-residential setting, the span of
  time between services exceeds two days, the
  notice must be given no later than the next to
  last time services are furnished.

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Provider Responsibility Content of
Advance Notice

• Date that coverage of service ends
• Date beneficiarys financial liability begins
• Description of right to appeal
• Description of right to detailed information
• Any other information required by CMS

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Provider Responsibility Valid
Notice

• Beneficiary signed and dated notice
• The timing of delivery was appropriate
• The content of the notice is correct

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Provider Responsibility 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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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 (effective date), whichever is
  later.

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Medicare Beneficiary May Appeal If

• Non-residential provider (HHA/CORF)
• Beneficiary disagrees with termination of service
  and
• Physician certifies that failure to continue the
  service may place the beneficiarys health at
  significant risk

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Medicare Beneficiary May Appeal If

• Residential provider (SNF) or hospice
• Beneficiary disagrees with discharge decision

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Medicare Beneficiary Appeal Request

• The beneficiary (or representative) must
  request a QIO expedited appeal by noon of the day
  prior to termination of service(s).

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Medicare Beneficiary Untimely Appeal

• If a valid notice was issued, a non-expedited
  QIO review is performed
• Make a decision as soon as possible

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Provider Responsibility Expedited
Review

• Send detailed notice to the beneficiary by
  close of business of the day of the QIOs
  notification

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Provider Responsibility Detailed Notice
Content

• Specific and detailed explanation why services
  are either no longer reasonable and necessary or
  are no longer covered

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Provider Responsibility Detailed Notice
(continued)

• Description of 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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Provider Responsibility Detailed Notice
(continued)

• Facts specific to the beneficiary and relevant
  to the coverage determination that are sufficient
  to advise the beneficiary of the applicability of
  the coverage rule or policy to the beneficiarys
  case
• Any other information required by CMS

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Provider Responsibility Information to
QIO

• Supply all information, including a copy of the
  advance and detailed notices
• For expedited appeals, this information should be
  furnished not later than by close of business of
  the day the QIO notified the provider of the
  appeal

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Provider Responsibility Information to
QIO

• The provider may be held financially liable in
  continued coverage if a delay results from the
  provider failing to supply requested information
  in a timely manner

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Responsibility of the QIO Expedited
Review

• Immediately notify provider of appeal request
• Determine if notice is valid
• Examine medical and other records pertaining to
  services in dispute
• Includes, if applicable, physician certification

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Responsibility of the QIO Expedited
Review

• Within 72 hours from receipt of an expedited
  appeal request, the QIO must make a determination
  on whether termination of Medicare coverage is
  the correct decision

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Responsibility of the QIO Determination

• Notify the beneficiary (or representative),
  beneficiarys physician, and the health care
  provider
• Initial notification may be made by telephone
• A written notification must follow

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Responsibility of the QIO Written
Notification

• Rationale for determination
• Explanation of the Medicare payment consequences
  and the date the beneficiary becomes fully liable
  for services
• Information about reconsideration rights,
  including how to request and the time period

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Medicare Beneficiary
Reconsideration Request

• If the beneficiary disagrees with the QIOs
  initial appeal determination, he or she may
  request a reconsideration.
• Only the beneficiary (or representative) may ask
  for a reconsideration

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Medicare Beneficiary
Reconsideration Request

• Qualified Independent Contractors (QIC) will
  perform reconsiderations.

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ALJ Review Request

• QICs will prepare cases for ALJ review

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Coverage of Provider Services

• Coverage continues until the date and time
  designated on the termination notice, unless the
  QIO or QIC reverses the providers service
  termination decision

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Coverage of Provider Services (continued)

• Do not bill the beneficiary for any disputed
  services until the expedited determination
  process (and reconsideration process, if
  applicable) has been completed.

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Coverage of Provider Services (continued)

• If the QIOs decision is delayed because the
  provider did not timely supply necessary
  information or records, the provider may be
  liable for costs of any additional coverage.

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Coverage of Provider Services (continued)

• If the QIO determines that the beneficiary did
  not receive a valid notice, coverage of provider
  services continues until at least two calendar
  days after a valid notice has been received.

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Provider Responsibility Releasing Information
to Beneficiary

• At a beneficiarys request, the provider must
  furnish the beneficiary with a copy of, or access
  to, any documentation that it sends to the QIO.

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AQAF Contacts 1-800-760-4550

• Pam Taylor, Beneficiary Protection Program
  Leader, ext. 3512
• Joan Wilder, Review Coordinator, ext. 3218
• Barbara Baites, Review Coordinator, ext. 3228
• Anita Meyers, Review Coordinator, ext. 3217
• Laura Rutledge, Review Coordinator, ext. 3429
• Cathy Dixon, Review Coordinator, ext. 3426

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Questions?
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HOW DOES ALL OF THIS WORK?
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REFERENCES

• cms.hhs.gov/regulations/pra
• cms.hhs.gov/medicare/bni
• MedLearn
• CMS Provider ListServe

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BIPA Appeals Number

• AQAFs Appeals Hotline
• 1-800-366-1486
• Insert this number on the notice

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Alabama Quality Assurance Foundation
This material was prepared by Alabama Quality
Assurance Foundation (AQAF), the Medicare
Quality Improvement Organization for Alabama
under contract with the Centers for Medicare
Medicaid Services (CMS), an agency of the U.S.
Department of Health Human Services. The
contents presented do not necessarily reflect
CMS policy. 7SOW-AL-GEN-05-34