Northeast Health Care Quality Foundation

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Northeast Health Care Quality Foundation

• Notice of Medicare Provider
• Non-Coverage and QIO Review
• (aka Expedited Determination (ED) Notice, Generic
  Notice)
• 11/4/09 and 11/10/09
• The enclosed material was prepared and assembled
  by Northeast Health Care Quality Foundation
  (NHCQF), the Medicare Quality Improvement
  Organization (QIO) for Maine, New Hampshire and
  Vermont, under contract with the Centers for
  Medicare Medicaid Services (CMS), an agency of
  the U.S. Department of Health and Human Services.
  The contents presented do not necessarily
  reflect CMS policy.
  
  2009-934-6.1-MNV

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Presentation Summary

• Overview of notice issuance requirements
• Overview of appeal process
• Issues identified by NHCQF
• Q As

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CMS Official Website for Notice Information

• http//www.cms.hhs.gov/medicare/bni
• Scroll down menu on left
• Select FFS ED Notices or MA ED Notices
• Downloads include
• Expedited generic notice and detailed notice
  (English and Spanish)
• Notice instructions
• QAs
• General information
• MA includes notices and instructions only

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Basic Notice Requirement

• Before any termination of skilled services, the
  provider must deliver a valid written notice to
  the beneficiary or representative of the decision
  to terminate services. (Includes situations
  where the beneficiary or representative agrees
  with termination.)
• Applicable settings include SNFs, HHAs, hospices,
  hospital swing beds, CORFs

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Termination of Medicare Covered Services

• Complete cessation of coverage at the end of a
  course of treatment
• Does not include
• Reduction in services with some skilled services
  remaining
• Discharge to acute setting
• Discharge to same setting
• Exhaustion of benefits
• DME
• Beneficiary terminates services

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Valid Written Notice

• Fee for service (FFS) vs Medicare Advantage (MA)
  Notices
• OMB Approval No. 0938-0953 (FFS) Form No.
  CMS-10124, Exp. Date 7/31/11
• OMB Approval No. 0938-0910 (MA) Form No. CMS-
  10095, Exp. Date 8/31/10
• Cannot be issued to beneficiary if beneficiary
  unable to understand notice
• Required content and timing

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Required Content

• Provider contact information
• Name of beneficiary
• Effective date/last day of covered services
• QIO appeal rights and contact information
• Include OMB number
• Use current form

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Required Timing

• Issue no later than 2 calendar days before the
  proposed effective date/last covered day (for
  example, if the effective date is Friday, the
  notice must be issued Wednesday at the latest)
• If services are fewer than 2 days in duration,
  issue notice at the start of services

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Telephone Notification

• If personal delivery not immediately available,
  may notify by telephone
• Be sure to explain
• Effective date
• Appeal rights
• How to contact QIO
• Time frame for requesting a timely appeal
• Document date and time of call and information
  provided
• Mail notice on same day as telephone notification

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Notification by Mail

• If telephone contact cannot be made, mail the
  notice by certified mail, return receipt
  requested
• Date of receipt is date signed for (or signature
  refused)
• If notice returned by post office undeliverable,
  receipt of notice considered to be second working
  day after mailing date
• Liability begins third calendar day after receipt

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Timely Appeal Request

• The beneficiary (or representative) must request
  a QIO expedited appeal by noon of the day prior
  to the effective date/last covered day
• The QIO will complete the review within 3
  calendar days of receipt of the appeal request
  (FFS)
• The QIO will complete the review within 1
  calendar day of receipt of the medical record and
  notices (MA)

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Untimely Appeal Request (FFS)

• The beneficiary or representative may request an
  appeal within 60 days from effective date
• QIO will complete the review within 7 days if
  beneficiary still receiving services
• QIO will complete the review within 30 days if
  beneficiary no longer receiving services

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Untimely Appeal Request (MA)

• No QIO appeal
• Beneficiaries/representatives may contact the
  plan for an appeal

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QIO Notifies Provider

• Immediately notify provider or plan of appeal
  request
• Instruct provider or plan to issue detailed
  notice
• Request notices and medical records be faxed to
  QIO
• Seven day a week process, including weekends and
  holidays

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Special Procedure for HHA Appeals

• Regulations do not allow QIOs to process appeal
  (except for review of notice) until a physician
  certifies that failure to continue the service
  may place the beneficiarys health at significant
  risk
• QIO will not request the detailed notice or the
  medical record until certification received

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Issuance of Detailed Notice

• Reference CMSs BNI website for the official
  notice and instructions
• Detailed notice should include
• Explanation why services are no longer covered,
• Description of applicable coverage or policy
  rules,
• Facts specific to the beneficiary and relevant to
  the coverage determination
• Do not need beneficiarys or representatives
  signature on the detailed notice

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Send Documentation by Fax

• Provide all information requested, including a
  copy of the generic and detailed notices, and the
  medical record information
• Fax no later than by close of business on the day
  notified of the appeal, or asap the following day
  if notification late in the day
• Complete medical record not needed, QIO may
  request additional information during review
  process

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QIO Review Determination

• Made by QIO Physician Consultant after nurse
  reviewer discussion with attending physician,
  provider and the beneficiary or representative
• Given to beneficiary or representative, attending
  physician, and provider by telephone, followed by
  written notification
• Includes reconsideration rights

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Reconsideration

• If the beneficiary or representative disagrees
  with the QIOs initial expedited appeal
  determination, he or she may request a
  reconsideration
• FFS reconsideration is performed by the QIC
  (qualified independent contractor) - Maximus
• MA reconsideration is performed by the QIO

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Medicare Coverage of Provider Services

• Coverage stops after the effective date
  designated on the termination notice, unless QIO
  reverses the providers termination decision
• QIO may reverse determination if medical record
  information not provided timely
• Do not bill the beneficiary for any disputed
  services until the appeal and reconsideration (if
  applicable) have been completed

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Appeal Outcomes (ME, NH, VT)August 2008-October
2009

• FFS Reviews 151
• 3 reversed (QIO agrees with provider in 98 of
  the cases)
• MA Reviews 13
• 5 reversed (QIO agrees with plan in 62 of the
  cases)
• Rescinded notices 24
• Invalid notices 12

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Rescissions

• Provider decides notice should not have
  been issued
• Write rescinded and date of rescission on
  notice
• Give copy to beneficiary/representative
• Fax copy to QIO if appeal has been requested

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Invalid Notice

• QIO notifies beneficiary/representative and
  provider
• When reissuing the notice, the effective date
  remains the same include the following statement
  on the new notice
• We are giving you another notice because the QIO
  decided the previous notice we gave you on
  (insert date) was invalid. You will not have to
  pay for any care you receive until the 3rd day
  after you receive this notice. You must call the
  QIO again, within 24 hours after receiving this
  new notice, if you still want the QIO to review
  the decision to end your Medicare coverage.

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Reasons for Invalid Notices

• Wrong notice form used (FFS vs MA vs other)
• Provider did not give appeal rights and/or QIO
  contact information
• Information missing or incorrect on form
• Information not provided with telephone
  notification
• Notice issued to beneficiary who cannot
  understand it (for example, beneficiary has
  dementia)
• No effective date given or notice not issued in
  required time frame

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NHCQF Contact Information

• Toll-free helpline 1-800-772-0151
• Fax [phone]
• Website www.nhcqf.org
• QUESTIONS?