Centers%20for%20Medicare%20and%20Medicaid%20Services%20Presentation

1
Centers for Medicare and Medicaid
ServicesPresentation

• by Mary Ann Grandlich
• for the Western Claim Conference

2
Whats the Latest News at CMS?

• Final rule for MedicareChoice (MCO) appeals
  (Grijalva v. Shalala)
• Release of 2004 MCO rates

3
Tips from the RO

• Quick Summary of Grijalva Changes
• RO Letter-- Payment of Ambulance Claims
• CWF--Plan Communications Users Guide
• RO Letter-- Clarification of Requirements for
  Pharmacy Denials
• HIPAA Resources

4
2004 MCO Payment Rates

• 2 minimum increase
• Presidents plan to expand choice while
  strengthening managed care
• More accurate risk adjustment methodology

5
Risk Adjustment Model

• New risk adjustment methodology effective 2004
• Phase in at 30, 50, 75 , 100
• Hierarchical Condition Model (HCC)

6
HCC

• Increase payments for the sickest beneficiaries
• Selected significant disease model
• Encourages MCOs to to utilize disease management
  programs
• Http//cms.hhs.gov/healthplans/rates/default.asp

7
Final Appeal Rule

• Right to immediate review of discharge decision
  if beneficiary believes services should continue
• Advance written notice to all MCO beneficiaries 2
  days before termination of certain services
• On request a specific and detailed explanation

8
Appeals Changes

• Notification of Noncoverage (NODMAR)
• Only required if beneficiary disagrees with
  discharge decision
• Notice must be issued no later than day before
  hospital coverage ends
• If beneficiary files complaint with the QIO, the
  beneficiary not liable until noon of day
  following decision

9
Termination of Provider Services

• Includes only SNF, HHA and outpatient rehab.
  facilities
• Definition
• Cessation of course of treatment
• Discharge from covered services
• Discontinuation of covered provider services

10
Notice Requirements

• Include
• Date coverage ends and date financial liability
  begins
• Right to fast track appeal
• Right to detailed information on why coverage is
  ending

11
Notice Requirements cont.

• Beneficiary or authorized representative must
  sign and date the notice
• If beneficiary agrees with discharge sooner than
  2 days may waive continuation of services

12
Payment of Ambulance Claims

• Mandatory assignment and phase in of AFS
• 4/1/02-12/31/02 80 20
• 2003 60 40
• 2004 40 60
• 2005 20 80
• 2006 0 100

13
Ambulance Fee Schedule

• Available on CMS website
• http/cms.hhs.gov/suppliers/ambulance/default.asp

14
Suppliers Reasonable Charge Profile

• Contact Medicare Part B Carrier
• For Arizona, Nevada, and Hawaii
• nancy.lee_at_noridan.com
• For California
• kathy.montoya_at_eds.com
• For other carriers
• http//cms.hhs.gov/medlearn/tollnums.asp

15
Common Working File

• MCOs have access to
• A national system with
• Eligibility, ESRD, hospice and utilization data
• inpatient spell data, home health visits,
  lifetime reserve days and lifetime inpatient
  psychiatric days

16
CWF cont.

• cms.hhs.gov/healthplans/systems/Guides.asp
• For Plan Communications Users Guide
• MCOs must obtain a user ID and password to access
  CWF

17
Pharmacy Denials

• Generally verbal denials
• Referral to MCO if beneficiary disagrees
• Written notice with appeal rights

18
HIPAA DEADLINES

• April 16, 2003 Begin testing HIPAA compliant
  software
• October 16, 2003 Implement electronic
  transactions and code sets

19
HIPAA Help

• Sign up for two list serves.
• They are free!
• They are sponsored by the government
• They automatically send you e-mails
• See handout, fourth bullet