Medicare Choice Appeals Conference

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Medicare Choice AppealsConference

• MAXIMUS Center for Health Dispute Resolution

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Medicare Managed Care Reconsideration Project

• New at MAXIMUS CHDR
• Working with MAXIMUS CHDR
• Appeals Data

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Whats New

• ISO 90012000 Certified
• New Manual
• New Website

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Quality Policy

• All staff and suppliers to MAXIMUS CHDR
  understand and meet or exceed, customer
  requirements so as to provide timely, unbiased,
  expert medical insurance appeal determinations,
  thereby assisting our government clients to
  better serve the people.

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ISO 90012000What is it?

• Internationally recognized quality management
  system standard
• Developed by International Organization of
  Standardization
• Emphasizes quality standards in
• Systems
• Procedures
• Documentation

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ISO 90012000What does certification mean?

• MAXIMUS CHDR subject to audit conducted by
  outside independent auditor.
• Independent auditor determines whether the
  procedures, practices and quality systems meets
  the defined ISO standards.
• MAXIMUS CHDR passed initial audit with no
  findings.
• Periodic re-certification.

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Impact on Medicare Managed Care Reconsideration
Project

• Decision Processing
• Appeal Officers
• Independent Physician Consultants
• Internal Audit

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Decision Processing

• Documented MAXIMUS CHDR appeal processing
• Increased Internal Quality Reviews

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Appeal Officer

• Created specialized teams
• Team Leaders
• Over 30 years combined experience
• Monitor timeliness/quality
• Quality Reviews
• Increased sample on monthly basis for each team
  member
• Internal Quality Control Monitoring Tool used to
  capture and measure

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Independent Physician Consultant

• Structured medical review instrument, with
  attestation
• Verified assessment of medical reviewers cases
  by 1st level reviewer
• Review by Medical Director or peer of
  questionable medical reviewer determinations

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Independent Physician Consultant

• Review of new medical reviewers cases by Medical
  Director or peer until production of two
  error-free reviews in a row
• Sampling of at least five percent of decisions on
  an annualized basis
• Documented real time feedback to reviewers for
  corrective action (for example, re-education)

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Customer Contact

• Customer defined as CMS, Medicare managed care
  plans and enrollees
• MAXIMUS CHDR welcomes comments, suggestions and
  feedback
• Continuous cycle of feedback, evaluation,
  improvement

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MC Reconsideration Process Manual

• Effective January 2003
• Includes information on
• How to contact MAXIMUS CHDR
• Considerations for development
• How to submit case file to MAXIMUS CHDR
• MAXIMUS CHDR Reconsideration Process
• New data collection efforts
• New decision letters

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Medicare Managed Care Reconsideration Project
Web Site
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Medicare Managed Care Reconsideration Project
Web Site

• Located at www.medicareappeal.com
• Pages for enrollees, health plans, researchers
• Case status search
• Updated daily (1.5 day lag from case
  receipt/action)
• Search by case number or plan contract number
• Problems with web site? Contact us at
  medicareappeal_at_maximus.com

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Medicare Managed Care Reconsideration Project Web
Site
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Working with MAXIMUS CHDR

• Reconsideration Background Data Form
• Case file submission
• Submitting additional information
• Reopening requests
• Data Reports

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Reconsideration Background Data Form

• Common Issues
• Case Class
• Processing Dates
• Impact on Data Reports to CMS

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Reconsideration Background Data FormCommon
Issues

• Enrollee Medicare
• Validate Enrollment
• Incorrect number delays case initiation
• Plan Contract
• Validate MCO
• Compliance Reporting
• Recycled Forms Representative Issues

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Reconsideration Background Data FormCase Class

• MAXIMUS CHDR can change class at its level.
• Examples
• -Claim appeals cannot be expedited
• -Certain SNF appeals

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Reconsideration Background Data FormPlan
Processing Dates

• Section VI(B) Reconsideration Determination
  Processing Dates
• Date of valid appeal request
• Date of decision by Plan
• What is a valid appeal?

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Reconsideration Background Data FormImpact on
Data Reports

• Representative Documentation
• Date of valid appeal request means date valid AOR
  received by plan
• If no valid AOR received, then no date of appeal
  request

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Reconsideration Background Data FormImpact on
Data Reports

• Plan Contract Identification
• Use contract number of enrollees plan
• Plan Processing Timeliness
• -MAXIMUS CHDR reports plan timeliness using
  reconsideration dates provided on the
  Reconsideration Background Data Form
• -MAXIMUS CHDR separately captures discrepancy data

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Reconsideration Background Data Form Correcting
Plan Error

• Corrections before report provided to CMS
• Do not send in new RBDF
• Provide information in writing to MAXIMUS CHDR
• Retain in file
• After timeliness report provided to CMS
• Send information to MAXIMUS CHDR and CMS
• MAXIMUS CHDR will not change data
• MAXIMUS CHDR will not re-run reports

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Reconsideration Background Data FormCorrecting
MAXIMUS CHDR Error

• Send written notice to MAXIMUS CHDR
• MAXIMUS CHDR will research and report back to the
  Plan and CMS any errors made in recording data
• MAXIMUS CHDR will correct data errors
• MAXIMUS CHDR will not re-run report

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Submitting New Case File

• Must include completed Reconsideration Background
  Data Form
• Please separate multiple cases submitted in one
  package
• Expedited Cases submit only NOI via fax
• MAXIMUS CHDR will not accept cases sent via
  facsimile

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Submitting Additional Information

• Include case number and enrollee name
• Do not re-send Reconsideration Background Data
  Form as part of additional information submission
• Do not send medical records via facsimile

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Reopening Requests

• Make reopening request in writing
• Not an automatic appeal for OT decisions
• Only granted when
• Error on the face of the evidence,
• New information not previously available, or
• Fraud

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MAXIMUS CHDR Enhanced Data Collection

• Plan processing discrepancies
• Actual document (e.g. appeal letter, denial
  notice)
• RBDF
• Case narrative
• Organization Determination Notice
• Plan denial and decision reasons
• Enrollee arguments

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Data Reports

• Monthly Reports
• Appeal receipt volume
• Data on disposition of completed cases
• Quarterly Reports
• Plan timeliness
• Compliance Reports
• Annual Reports
• Available through www.medicareappeal.com

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Quarterly ReportsPlan Processing Timeliness

• Interval reported based on MCO supplied
  information in Reconsideration Background Data
  Form and date of case receipt
• Standard appeal cases assume 5 day period for
  mailing
• Expedited cases assume 1 day period for mailing

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Quarterly ReportsCompliance Reports

• Identifies whether MAXIMUS CHDR has received
  compliance statement for OT cases
• Notice sent to Plan by MAXIMUS CHDR
• Notice gives plan approx. 2 weeks to correct
  before reported to CMS

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Quarterly Reports Compliance Reports Helpful
Hints

• Use Statement of Compliance included in OT
  decision
• Can send Statement of Compliance by fax
• MAXIMUS CHDR does not accept questionable
  compliance statements such as planning to
  authorize
• MAXIMUS CHDR will send questionable compliance
  statements to CMS RO

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Appeals Data - Nation Cases Received by Category
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Appeals Data Region II Cases Received by
Category
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Appeals Data Nation Cases Received by Case Class
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Appeals Data Region II Cases Received by Case
Class
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Appeals Data - MCO Mean Time Case Process (Days)
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Appeals Data - MAXIMUS CHDR Mean Time Case
Process (Days)
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Appeals Data - Comparison Cases in which RI Made
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• MAXIMUS CHDR
• Contact us at
• medicareappeal_at_maximus.com
• 585-586-1770