Understanding BIPA FFS Fast Track Appeals

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Understanding BIPA FFS Fast Track Appeals

• Donna Ugan, RN, CLNC
• December 7, 2005

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Objectives

• Define BIPA and why it was implemented by CMS
• Identify the providers effected by BIPA
• Define a residential and non-residential provider
• Define a generic notice and the required content
  of the notice
• Issue a generic notice within the appropriate
  time frame defined by CMS
• Identify the CMS web site for resources, notices,
  and questions related to BIPA

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Background

• 42 CFR 405.1200-1206
• A beneficiary may obtain an expedited
  determination in response to the termination of
  provider services.

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Affected Providers

• Skilled Nursing Facilities (SNF)
• Swing Bed Providers
• Home Health Agencies (HHA)
• Comprehensive Outpatient Rehabilitation
  Facilities (CORF)
• Hospice Providers

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Termination of Covered Services

• Discharge from a residential provider.
  (SNF,Hospice)
• Complete cessation of coverage the end of a
  course of treatment.
• Not to be used for
• Exhaustion of benefits
• Reduction in services
• Hospital transfer (i.e.patient has pneumonia and
  is transferred to acute care)
• Refusal of care

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Notice Types

• Providers must issue an advanced or generic
  notice to all beneficiaries whose services are
  ending.
• Providers must issue a detailed notice to all
  beneficiaries who are appealing their discharge
  from services.
• Final notices are available online at
  http\\cms.hhs.gov\medicare\bni

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Content of Notice

• Name of beneficiary
• Beneficiarys HIC number
• Date that coverage of services end
• Description of appeal rights
• Type of coverage ending (SNF, HHA, etc)
• Name, address and telephone number of the
  appropriate QIO
• Rock Run Center, Suite 100
• 5700 Lombardo Center Drive
• Seven Hills, OH 44131
• 1-800-589-7337

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Timing of Notice Delivery

• Issued no later than two days or the second to
  the last visit before the proposed end of
  services.
• If services are fewer than two days in duration,
  notice should be issued at the time of admission.
• Notices may be given prior to the required
  deadline and CMS encourages this whenever
  possible.
• Day of Discharge, last covered day and
  effective date are interchangeable.

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Provider Responsibility

• Before any termination of services, the provider
  must deliver a valid written notice to the
  beneficiary of the decision to terminate
  services.
• Notice to be delivered personally
• With signed copy in the chart, original to the
  patient
• Notices may be delivered by phone in the event
  that a physician visit results in termination of
  services (HHA). The notice is then to be mailed
  immediately.
• When an appeal is requested through the QIO, the
  provider must provide a copy of the detailed
  notice to the QIO and the beneficiary by close of
  business the same day.

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Beneficiary May Appeal

• Non-residential provider (CORF HHA)
• Beneficiary disagrees with termination AND
• Physician certifies that failure to continue the
  services may place the beneficiarys health at
  significant risk
• Residential providers (SNF Hospice)
• Beneficiary disagrees with discharge decision

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Valid Notice

• Beneficiary or representative signature
• Timing of notice appropriate
• Content of notice correct
• Notices must be written in at least 12 point font
  and notices may be hand-written

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Financial Liability

• The provider is liable for continued services
  until two days after the beneficiary receives a
  valid notice.
• If the QIO upholds the notice, the beneficiary is
  financially liable for services received after
  the last covered day.
• If the QIO overturns the notice, Medicare will
  continue to cover services.
• If the QIO determines that the beneficiary did
  not receive a valid notice, coverage of provider
  services continues until at least two days after
  a valid notice has been issued/received.

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Appeal Process

• Beneficiary requests Appeal
• QIO Notifies facility and requests copies of
  notices and medical record
• Provider faxes information to QIO. Facility must
  be able to fax information 7 days a week.
• QIO physician makes determination
• QIO notifies provider, physician, beneficiary of
  determination
• QIO mails written determination

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Beneficiary ResponsibilityReconsideration

• If the beneficiary disagrees with the QIOs
  initial expedited or non-expedited appeal
  determination, he or she may request
  reconsideration.
• Reconsiderations are performed by Qualified
  Independent Contractors (QIC)
• Only the beneficiary or representative may ask
  for reconsideration.

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BIPA Web Site
Please visit Ohio KePROs Web site to view BIPA
information and to download forms and
materials. Go to www.ohiokepro.com Click on
Providers/Case Review/BIPA
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Questions?
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CNE Information
To obtain your credits, you must attend 100 and
complete the on-line evaluation at
http//www.ohiokepro.com/providers/hospital/events
.asp. Please print out your certificate
on-line. (Approval for CNE credits is currently
pending.) If you have any questions, please
call Rosann Pasko Ohio KePRO 1-800-385-5080
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Publication No. 4226-OH-010-7/2005. This
material was prepared by Ohio KePRO, the Medicare
Quality Improvement Organization for Ohio, 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.