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Sign-on Letter: Improving Seniors’ Timely Access to Care Act

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Sign-on Letter: Improving Seniors’ Timely Access to Care Act

September 9, 2019

Dear Members of Congress:

The undersigned patient, physician, health care professional, and other health care stakeholder
organizations strongly support the Improving Seniors’ Timely Access to Care Act of 2019 (H.R.
3107) recently introduced by Reps. Suzan DelBene (D-WA), Mike Kelly (R-PA), Roger
Marshall, MD (R-KS), and Ami Bera, MD (D-CA). This bipartisan legislation would help
protect patients from unnecessary delays in care by streamlining and standardizing prior
authorization under the Medicare Advantage program, providing much-needed oversight and
transparency of health insurance for America’s seniors. We urge you to join your colleagues in
supporting this important legislation.

Based on a consensus statement on prior authorization reform adopted by leading national
organizations representing physicians, medical groups, hospitals, pharmacists, and health plans,
the legislation would facilitate electronic prior authorization, improve transparency for
beneficiaries and providers alike, and increase Centers for Medicare & Medicaid Services (CMS)
oversight on how Medicare Advantage plans use prior authorization. Specifically, the bill
would:

  • Create an electronic prior authorization program including the electronic transmission of
    prior authorization requests and responses and a real-time process for items and services
    that are routinely approved;
  • Improve transparency by requiring plans to report to CMS on the extent of their use of
    prior authorization and the rate of approvals or denials;
  • Require plans to adopt transparent prior authorization programs that are reviewed
    annually, adhere to evidence-based medical guidelines, and include continuity of care for
    individuals transitioning between coverage policies to minimize any disruption in care;
  • Hold plans accountable for making timely prior authorization determinations and to
    provide rationales for denials; and
  • Prohibit additional prior authorization for medically-necessary services performed during
    a surgical or invasive procedure that already received, or did not initially require, prior
    authorization.

The demand and need for such reforms is growing — particularly as more seniors choose
Medicare Advantage for their health insurance needs. According to a recently released Kaiser
Family Foundation report, “A Dozen Facts About Medicare Advantage in 2019,” Medicare
Advantage enrollment has nearly doubled in a decade. One-third (34%) of all Medicare
beneficiaries — 22 million people — are enrolled in Medicare Advantage plans, and nearly four
out of five enrollees (79%) are in plans that require prior authorization for some services. The
Congressional Budget Office (CBO) projects that beneficiaries enrolled in Medicare Advantage
plans will rise to nearly half of all Medicare beneficiaries (about 47%) by 2029. Recognizing the
need to protect a growing number of Medicare beneficiaries, more than 100 members of
Congress called for such reforms in a letter last year to the CMS.

For our seniors — and as representatives of organizations seeking to protect patients from delays
in care and relieve unnecessary administrative burdens that impede delivery of timely care—we
are committed to advancing this legislation in Congress and ask that you join Representatives
DelBene, Kelly, Marshall, and Bera in co-sponsoring H.R. 3107 and securing its enactment.
Thank you.

Sincerely,

ACCSES
Aimed Alliance
Alliance for Aging Research
Alliance for Balanced Pain Management
Alliance for Patient Access
Alliance of Specialty Medicine
Alzheimer’s Association
Alzheimer’s Impact Movement
AMDA – The Society for Post-Acute and Long-Term Care Medicine
American Academy of Allergy, Asthma & Immunology
American Academy of Dermatology Association
American Academy of Facial Plastic and Reconstructive Surgery
American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Otolaryngology – Head and Neck Surgery
American Academy of PAs
American Academy of Physical Medicine & Rehabilitation
American Academy of Sleep Medicine
American Alliance of Orthopaedic Executives
American Association of Clinical Endocrinologists
American Association of Clinical Urologists
American Association of Hip and Knee Surgeons
American Association of Neurological Surgeons
American Association of Nurse Practitioners
American Association of Orthopaedic Surgeons
American Association of Pediatric Ophthalmology and Strabismus
American Association on Health and Disability
American Autoimmune Related Diseases Association
American Brain Coalition
American Cancer Society Cancer Action Network
American Clinical Laboratory Association
American Clinical Neurophysiology Society
American College of Allergy, Asthma and Immunology
American College of Cardiology
American College of Emergency Physicians
American College of Gastroenterology
American College of Mohs Surgery
American College of Obstetricians and Gynecologists
American College of Osteopathic Surgeons
American College of Physicians
American College of Radiation Oncology
American College of Radiology
American College of Rheumatology
American College of Surgeons
American Congress of Rehabilitation Medicine
American Dance Therapy Association
American Gastroenterological Association
American Geriatrics Society
American Glaucoma Society
American Group Psychotherapy Association
American Liver Foundation
American Medical Association
American Medical Rehabilitation Providers Association
American Medical Women’s Association
American Music Therapy Association
American Nurses Association
American Occupational Therapy Association
American Osteopathic Association
American Osteopathic Colleges of Ophthalmology and Otolaryngology
American Physical Therapy Association
American Psychiatric Association
American Psychoanalytic Association
American Society for Clinical Pathology
American Society for Gastrointestinal Endoscopy
American Society for Radiation Oncology
American Society for Radiology and Oncology
American Society for Surgery of the Hand
American Society of Anesthesiologists
American Society of Cataract & Refractive Surgery
American Society of Clinical Oncology
American Society of Echocardiography
American Society of Hematology
American Society of Interventional Pain Physicians
American Society of Nephrology
American Society of Neuroimaging
American Society of Neuroradiology
American Society of Nuclear Cardiology
American Society of Ophthalmic Plastic and Reconstructive Surgery
American Society of Plastic Surgeons
American Society of Retina Specialists
American Society of Transplant Surgeons
American Spinal Injury Association
American Urological Association
American Uveitis Society
American Vein & Lymphatic Society
American-European Congress of Ophthalmic Surgery
America’s Physician Groups
Arthritis Foundation
Association for Molecular Pathology
Association of Academic Physiatrists
Association of American Medical Colleges
Association of Black Cardiologists
Association of Rehabilitation Nurses
Association of University Professors of Ophthalmology
Beyond Type 1
Brain Injury Association of America
Bridge the Gap – SYNGAP Education and Research Foundation
Cancer Support Community
CancerCare
Caregiver Action Network
Child Neurology Foundation
Children with Diabetes
Christopher & Dana Reeve Foundation
Clinician Task Force
CMSC- Consortium of Multiple Sclerosis Centers
Coalition For Headache And Migraine Patients
College Diabetes Network
College of American Pathologists
Community Oncology Alliance
Congress of Neurological Surgeons
Cornea Society
Crohn’s & Colitis Foundation
Delaware Academy of Ophthalmology
Depression and Bipolar Support Alliance
Derma Care Access Network
Diabetes Patient Advocacy Coalition
DiabetesSisters
Digestive Disease National Coalition
Disability Rights Education and Defense Fund
Dystonia Advocacy Network
Dystonia Medical Research Foundation
Epilepsy Foundation
Eye and Contact Lens Association
Eye Bank Association of America
Federation of American Hospitals
Free2Care
GBS|CIDP Foundation International
Global Alliance for Behavioral Health and Social Justice
Global Healthy Living Foundation
Global Liver Institute
Healthcare Information and Management Systems Society
Hematology/Oncology Pharmacy Association
IFAA – International Foundation for Autoimmune & Autoinflammatory Arthritis
International Essential Tremor Foundation
International Foundation for Gastrointestinal Disorders
International Society for the Advancement of Spine Surgery
Interstitial Cystitis Association
Lupus and Allied Diseases Association, Inc.
Medical Group Management Association
METAvivor
Movement Disorders Policy Coalition
Multiple Sclerosis Association of America
National Alopecia Areata Foundation
National Association for the Advancement of Orthotics & Prosthetics
National Association of Rural Health Clinics
National Association of Social Workers
National Association of Spine Specialists
National Association of State Head Injury Administrators
National Association of State Mental Health Program Directors
National Comprehensive Cancer Network
National Diabetes Volunteer Leadership Council
National Health Council
National Infusion Center Association
National Lipid Association
National Medical Association, Ophthalmology Section
National Multiple Sclerosis Society
National Osteoporosis Foundation
National Pancreas Foundation
National Patient Advocate Foundation
NephCure Kidney International
North American Neuro-Ophthalmology Society
Ocular Microbiology and Immunology Group
Outpatient Endovascular and Interventional Society
Partnership to Advance Cardiovascular Health
Partnership to Fight Chronic Disease
Partnership to Improve Patient Care
Prevent Blindness
Pulmonary Hypertension Association
Remote Cardiac Services Provider Group
Renal Physicians Association
Restless Legs Syndrome Foundation
RetireSafe
Sjogren’s Syndrome Foundation
Society for Cardiovascular Angiography and Interventions
Society for Vascular Surgery
Society of Critical Care Medicine
Society of Gynecologic Oncology
Society of Hospital Medicine
Spine Intervention Society
The Headache and Migraine Policy Forum
The Leukemia & Lymphoma Society
The Marfan Foundation
The Michael J. Fox Foundation for Parkinson’s Research
The Retina Society
The Society of Thoracic Surgeons
Tourette Association of America
Treatment Communities of America
Uniform Data System for Medical Rehabilitation
United Spinal Association
US Hereditary Angioedema Association
Alabama Academy of Ophthalmology
Alabama Society for the Rheumatic Diseases
Lakeshore Foundation
Medical Association of the State of Alabama
Neurosurgical Society of Alabama
Alaska Rheumatology Alliance
Alaska Society of Eye Physicians and Surgeons
Denali Oncology Group Alaska Chapter ASCO
Arizona Medical Association
Arizona Neurosurgical Society
Arizona United Rheumatology Alliance
The Arizona Clinical Oncology Society
Arkansas Medical Society
Arkansas Ophthalmological Society
Arkansas Rheumatology Association
Association of Northern California Oncologists
California Academy of Eye Physicians and Surgeons
California Association of Neurological Surgeons
California Medical Association
California Rheumatology Alliance
Medical Oncology Association of Southern California, Inc.
Cedars/Aspens, non-profit society of ophthalmic surgeon educators
Colorado Medical Society
Colorado Neurosurgical Society
Colorado Rheumatology Association
Colorado Society of Eye Physicians and Surgeons
Connecticut Rheumatology Association
Connecticut Society of Eye Physicians
Connecticut State Medical Society
Delaware Society for Clinical Oncology
Delaware State Neurosurgical Society
Medical Society of Delaware
Medical Society of the District of Columbia
Florida Medical Association
Florida Neurosurgical Society
Florida Society of Clinical Oncology
Florida Society of Ophthalmology
Florida Society of Rheumatology
Georgia Society of Clinical Oncology
Georgia Society of Rheumatology
Medical Association of Georgia
Hawaii Medical Association
Hawaii Society of Clinical Oncology
Association of Idaho Rheumatologists
Idaho Medical Association
Idaho Society of Ophthalmology
Illinois Medical Oncology Society
Illinois Society of Eye Physicians & Surgeons
Illinois State Medical Society
Illinois State Neurosurgical Society
Indiana Academy of Ophthalmology
Indiana Chapter, American College of Cardiology
Indiana Oncology Society
Iowa Medical Society
Iowa Oncology Society
Midwest Neurosurgical Society
Kansas Chapter, American College of Cardiology
Kansas Hospital Association
Kansas Medical Society
LeadingAge Kansas
Midwest Rheumatology Association
Kentucky Academy of Eye Physicians and Surgeons
Kentucky Association of Medical Oncology
Kentucky Chapter, American College of Cardiology
Kentucky Medical Association
Louisiana Academy of Eye Physicians and Surgeons
Louisiana Chapter, American College of Cardiology
Louisiana Neurosurgical Society
Louisiana State Medical Society
Rheumatology Alliance of Louisiana
Maine Medical Association
Maine Society of Eye Physicians and Surgeons
Maryland Chapter, American College of Cardiology
Maryland DC Society of Clinical Oncology
Maryland Society for the Rheumatic Diseases
Maryland Society of Eye Physicians and Surgeons
MedChi, The Maryland State Medical Society
Massachusetts Society of Clinical Oncologists
Massachusetts Medical Society
Michigan Society of Eye Physicians and Surgeons
Michigan Society of Hematology & Oncology
Michigan State Medical Society
Minnesota Medical Association
Minnesota Neurosurgical Society
Mississippi Arthritis and Rheumatism Society
Mississippi Oncology Society
Mississippi State Medical Association
Missouri Oncology Society
Missouri Society of Eye Physicians & Surgeons
Missouri State Medical Association
Montana Medical Association
Montana Neurosurgical Society
Montana State Oncology Society
Nebraska Chapter, American College of Cardiology
Nebraska Medical Association
Nebraska Rheumatology Society
Nevada State Medical Association
Northern New England Clinical Oncology Society
New Hampshire Medical Society
Medical Oncology Society of New Jersey
Medical Society of New Jersey
New Jersey Academy of Ophthalmology
New Jersey Neurosurgical Society
New Mexico Medical Society
Empire State Hematology & Oncology Society
Medical Society of the State of New York
New York State Neurosurgical Society
New York State Ophthalmological Society
New York State Rheumatology Society
North Carolina Medical Society
North Carolina Rheumatology Association
North Carolina Society of Eye Physicians & Surgeons
North Dakota Medical Association
North Dakota Society of Eye Physicians and Surgeons
Ohio Association of Rheumatology
Ohio Chapter, American College of Cardiology
Ohio Hematology Oncology Society
Ohio Ophthalmological Society
Ohio State Medical Association
Ohio State Neurosurgical Society
Oklahoma Academy of Ophthalmology
Oklahoma Chapter, American College of Cardiology
Oklahoma Neurosurgical Society
Oklahoma State Medical Association
Oregon Academy of Ophthalmology
Oregon Medical Association
Oregon Rheumatology Alliance
Oregon Society of Medical Oncology
Pennsylvania Academy of Ophthalmology
Pennsylvania Medical Society
Pennsylvania Neurosurgical Association
Pennsylvania Rheumatology Society
Philadelphia Rheumatism Society
Pittsburgh Ophthalmology Society
Pennsylvania Society of Oncology & Hematology
The Hospital and Healthsystem Association of Pennsylvania
Puerto Rico’s Hematology and Medical Oncology Association
Rhode Island Chapter, American College of Cardiology
Rhode Island Medical Society
Rhode Island Neurosurgical Society
Rhode Island Society of Eye Physicians and Surgeons
South Carolina Medical Association
South Carolina Oncology Society
South Carolina Rheumatism Society
South Carolina Society of Ophthalmology
South Dakota Academy of Ophthalmology
South Dakota State Medical Association
Tennessee Chapter, American College of Cardiology
Tennessee Medical Association
Tennessee Rheumatology Society
State of Texas Association of Rheumatologists
Texas Medical Association
Texas Ophthalmological Association
Society of Utah Medical Oncologists
Utah Medical Association
Utah Ophthalmology Society
Vermont Medical Society
Medical Society of Virginia
Virginia Association of Hematologist & Oncologist
Virginia Chapter, American College of Cardiology
Virginia Society of Eye Physicians and Surgeons
Neurosurgical Society of the Virginias

Washington Academy of Eye Physicians and Surgeons
Washington Rheumatology Alliance
Washington State Medical Association
Washington State Medical Oncology Society
West Virginia Academy of Eye Physicians & Surgeons
West Virginia State Medical Association
West Virginia State Rheumatology Society
Wisconsin Academy of Ophthalmology
Wisconsin Association of Hematology & Oncology
Wisconsin Medical Society
Wisconsin Rheumatology Association
Wisconsin State Neurosurgical Society
Wyoming County Community Health System
Wyoming Medical Society
Wyoming Ophthalmological Society

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Navigate the New Medicare ID Transition in Nine Steps

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Navigate the New Medicare ID Transition in Nine Steps

Due to a legislative mandate in MACRA passed in 2015, Medicare will no longer use Social Security numbers to identify individuals. Instead, a new randomly generated Medicare Beneficiary Identifier (MBI) will be assigned to all 58 million Medicare recipients. New Medicare ID cards containing the MBI are currently being sent to recipients.

The MBI replaces the Health Insurance Claim Number (HICN) used for Medicare transactions like billing, eligibility status, and claim status. Whereas the HICN started with the 10-digit Social Security number and ended with a letter or two designating a policy type, the 11-digit MBI will contain both letters and numbers throughout.

The transition to these new cards is a big step for patients as well as providers, and all stakeholders must be ready to accept, receive and transmit the new MBI.

Make the Transition in Nine Easy Steps

  • Educate practice staff about the rollout of the new Medicare cards with the new MBIs.
  • Contact practice-management system vendors about what system changes need to be made to accommodate the MBIs.
  • Alert your Medicare patients that they will be receiving new Medicare cards with their new MBIs.
  • Remind Medicare patients to confirm the Social Security Administration has their correct address on file to ensure they receive their new Medicare cards.
  • Tell Medicare patients to bring their new Medicare cards to their next appointment after they receive it.
  • Begin using the new MBI in Medicare transactions as soon as it is available for the patient.
  • Monitor eligibility responses for messages that indicate the patient was mailed a new Medicare card.
  • Starting Oct. 1, 2018, monitor remittance advices for messages that provide the patient’s MBI.
  • Sign up for the MBI look-up tool via your regional MAC portal.

For more information, log on to www.cms.gov and click the Medicare tab.

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Navigate the New Medicare ID Transition in 9 Steps

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Navigate the New Medicare ID Transition in 9 Steps

Due to a legislative mandate in MACRA passed in 2015, Medicare will no longer use social security numbers to identify individuals. Instead, a new randomly generated Medicare Beneficiary Identifier (MBI) will be assigned to all 58 million Medicare recipients. New Medicare ID cards containing the MBI are currently being sent to recipients.

“It is a big change,” said Phillip Allen, billing service manager with MediSYS. “MACRA requires that social security numbers be removed to protect beneficiaries from social security number theft, identity theft, and illegal use of benefits.” Which is why the gender and signature line will not be printed on the new Medicare cards either.

The MBI replaces the Health Insurance Claim Number (HICN) used for Medicare transactions like billing, eligibility status, and claim status. Whereas the HICN started with the 10-digit social security number and ended with a letter or two designating a policy type, the 11-digit MBI will contain both letters and numbers throughout.

The transition to these new cards is a big step for patients as well as providers. “All providers, vendors, and other stakeholders must be ready to accept, receive, and transmit the new MBI  … particularly for the new beneficiaries coming into the program,” said Monica Kay, acting director of the CMS division of program management.

Here are nine steps your practice should take to ease the transition and avoid payment delays:

  • Educate practice staff about the rollout of the new Medicare cards with the new MBIs.
  • Contact practice-management system vendors about what system changes need to be made to accommodate the MBIs.
  • Alert your Medicare patients that they will be receiving new Medicare cards with their new MBIs.
  • Remind Medicare patients to confirm that the Social Security Administration has their correct address on file to ensure that they receive their new Medicare cards.
  • Tell Medicare patients to bring their new Medicare cards to their next appointment after they receive it.
  • Begin using the new MBI in Medicare transactions as soon as it is available for the patient.
  • Monitor eligibility responses for messages that indicate the patient was mailed a new Medicare card.
  • Starting Oct. 1, 2018, monitor remittance advices for messages that provide the patient’s MBI.
  • Sign up for the MBI look-up tool via your regional MAC portal.
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CMS Reveals New Medicare Card Design; Strengthens Fraud Protections

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CMS Reveals New Medicare Card Design; Strengthens Fraud Protections

The Centers for Medicare & Medicaid Services has redesigned its Medicare card to remove Social Security numbers and use a unique, randomly-assigned number in an effort to better protect users from identity theft and fraud.

CMS will begin mailing the new cards to people with Medicare benefits in April 2018 to meet the statutory deadline for replacing all existing Medicare cards by April 2019. People with Medicare will also be able to see the design of the new Medicare card in the 2018 Medicare & You Handbook. The handbooks are being mailed and will arrive throughout September.

“The goal of the initiative to remove Social Security numbers from Medicare cards is to help prevent fraud, combat identify theft, and safeguard taxpayer dollars,” said CMS Administrator Seema Verma. “We’re very excited to share the new design.”

CMS has assigned all people with Medicare benefits a new, unique Medicare number, which contains a combination of numbers and uppercase letters. People with Medicare will receive a new Medicare card in the mail, and will be instructed to safely and securely destroy their current Medicare card and keep their new Medicare number confidential. Issuance of the new number will not change benefits that people with Medicare receive.

Health care providers and people with Medicare will be able to use secure look-up tools that will allow quick access to the new Medicare numbers when needed. There will also be a 21-month transition period where doctors, health care providers, and suppliers will be able to use either their current SSN-based Medicare Number or their new, unique Medicare number, to ease the transition.

This initiative takes important steps towards protecting the identities of people with Medicare. CMS is also working with healthcare providers to answer their questions and ensure that they have the information they need to make a successful transition to the new Medicare number. For more information, please visit: www.cms.gov/newcard.

How can providers get ready for the changes?

  • Ask your billing and office staff if your system can accept the new 11-digit alphanumeric Medicare Beneficiary Identifier or
  • If your system cannot accept the new number, system changes should be made by April 2018
  • If providers use vendors to bill Medicare, ask them about their MBI practice management system changes and make sure they are ready for the change
  • Verify your patients’ addresses: If the address you have on file is different than the address you get in electronic eligibility transaction responses, ask your patients to contact Social Security and update their Medicare records. This may require coordination between your billing and office staff.

For more information go to https://www.cms.gov/Medicare/New-Medicare-Card/Providers/Providers.html

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A Refresher in the Medicare Claims Appeals Process…

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A Refresher in the Medicare Claims Appeals Process…

With the increased audit activity we are seeing among the alphabet soup of Medicare contractors – RACs, ZPICs, SMRCs, CERTs, etc. – now appears to be a good time for a refresher on the Medicare claims appeals process. Due to this increased audit activity, more and more claims are being denied, both under pre-payment review and post-payment review. This article provides an overview on the Medicare claims appeals process, as well as some tips and pointers to keep in mind.

Request for Redetermination

A request for redetermination, the first level of appeal, must be filed within 120 days of receipt of a demand letter from the Medicare carrier (or, if no demand letter is received, within 120 days from the date a Medicare remittance advice shows a claim denial). If the request for redetermination is filed within the shorter time frame of 30 days, recoupment will not be initiated. If the request for redetermination is filed after the 30-day period, recoupment may be initiated, but will be stopped once the appeal has been filed. Interest begins to accrue on the 31st day and continues to accrue, even if an appeal is filed, until the overpayment is repaid or an entirely favorable decision is rendered. Thus, the only way to avoid the accrual of interest completely is to repay the overpayment before the 31st day. However, you still retain appeal rights even if the alleged overpayment has been repaid — you just have to go through the hassle of trying to get the money back from Medicare if a favorable decision is eventually rendered.
To ensure that all the relevant information is included, send a cover letter containing your arguments (with supporting documentation), as well as the request for redetermination form available at https://www.cahabagba.com/part-b/claims-2/appeals-2-2/.

The first level of appeal is reviewed by the applicable Medicare carrier, which for physicians practicing in Alabama is Cahaba GBA. The Medicare carrier has 60 days to render a decision.

Request for Reconsideration

A request for reconsideration, the second level of appeal, must be filed within 180 days of receipt of a decision by the Medicare carrier on
the request for redetermination filing. If the request for reconsideration is filed within the shorter time frame of 60 days, recoupment will not be initiated. If the request for reconsideration is filed after the 60-day period, recoupment may be initiated, but will be stopped once the appeal has been filed. Interest will continue to accrue, even if an appeal is filed, until the overpayment is repaid or an entirely favorable decision is rendered. Importantly, all information must be presented at the request for reconsideration level of appeal, as new information is generally not allowed to be presented at the following levels of appeal.

To ensure that all the relevant information is included, send a cover letter containing your arguments (with supporting documentation), as well as the request for reconsideration form available at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20033.pdf.

The second level of appeal is reviewed by the applicable Qualified Independent Contractor (“QIC”), an independent party hired by Medicare to review second level appeals. The QIC has 60 days to render a decision.

Administrative Law Judge

A request for a hearing before an Administrative Law Judge (“ALJ”), the third level of appeal, must be filed within 60 days of receipt of a decision by the QIC on the request for reconsideration, assuming the monetary thresholds are satisfied. Importantly, there is no opportunity to stop recoupment at this level of appeal. Thus, recoupment will begin and will continue until a favorable decision is rendered or until the full amount of the overpayment and accrued interest has been offset. Interest will continue to accrue at this level of appeal until the overpayment is repaid, offset through recoupment, or an entirely favorable decision is rendered.

To ensure that all the relevant information is included, utilize the ALJ hearing request form available at https://www.hhs.gov/about/agencies/omha/filing-an-appeal/coverage-and-claims-appeals/request-an-alj-hearing/index.html.

The ALJ hearing is usually conducted by telephone or video conference. By regulation, the hearing is supposed to take place and a decision rendered within 90 days of the appeal request. However, due to backlogs at the ALJ level, it is currently estimated that appeals will not be heard by ALJs for approximately 6-8 years, unless there is Congressional action to resolve the backlog. There is an option to escalate the appeal to the next level if a decision is not rendered timely in light of this delay. However, the success rate for providers at the ALJ level is relatively high, so bypassing this level of review is not always in the provider’s best interest. Nonetheless, despite the delay by the ALJ office, recoupment will continue.

Medicare Appeals Council

A request for review by the Medicare Appeals Council (“MAC”), the forth level of appeal, must be filed within 60 days of receipt of a decision from the ALJ, assuming the monetary threshold is satisfied. The MAC is supposed to render a decision within 90 days. However, due to backlogs, MAC decisions are also taking longer to be issued. There is an option to escalate the appeal to the next level if a decision is not rendered timely. However, such escalation is not always in the best interests of providers.

Judicial Review

A request for judicial review by the appropriate federal district court must be filed within 60 days from receipt of the MAC decision, assuming the monetary threshold is satisfied. From this point, the judicial system will oversee the proceeding.

A couple of points to keep in mind with respect to Medicare claims appeals. Be proactive – review the RAC website for approved audit issues, as well as the most-recent OIG Work Plan for target issues. Develop a formal intake and review process for records requests and demand letters. Always respond to records requests in a timely manner, as the failure to do so will result in an automatic claim denial. Keep track of denied claims and look for patterns. Determine corrective action to take, if applicable, and appeal as necessary and appropriate. If you appeal, file everything by a trackable delivery method and keep copies of all documents that are filed and received. Always ask for confirmation in writing when receiving advice or instruction from the applicable review body.

While the claims appeal process can be frustrating, time-consuming, and costly, providers tend to have a high degree of success. However, many providers simply pay the overpayment amount without challenging the finding due to the associated time and expense. Depending on the amount of the overpayment and the frequency with which you believe the pertinent issue has occurred within your practice, spending the time and effort to appeal may be beneficial.

Article contributed by Kelli Fleming, a partner at Burr & Forman LLP and practices exclusively in the Birmingham office within the Health Care Industry Group. Burr & Forman, LLP is a Bronze Partner with the Medical Association.

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Medicare Releases 2017 Physician Fee Schedule Final Rule

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Medicare Releases 2017 Physician Fee Schedule Final Rule

The Centers for Medicare and Medicaid Services released its final rule for its 2017 physician fee schedule payment policies, which updates payment policies and payment rates for services provided under the Medicare Physician Fee Schedule (PFS) starting Jan 1, 2017.

The 1,400-page 2017 final rule discusses changes to a number of new policies that reflect a broader agencywide strategy to enhance quality, spend smarter and improve Americans’ health.

Here are eight changes to note:

CMS will begin gathering data on postoperative visits. The final rule requires reporting of postoperative visits for high-volume/high-cost procedures by a sample of practitioners in practices with 10 or more physicians. Reporting is required for services related to global procedures provided on or after July 1, 2017.

Changes were made to provider and supplier requirements for Medicare Part C. Providers and suppliers will be screened and enrolled in Medicare to contract with a Medicare Advantage organization to provide items and services to those enrolled in Medicare Advantage health plans.

CMS finalized its proposal to expand eligible telehealth services. The additional codes include those for end-stage renal disease-related dialysis, advanced care planning and critical care consultations. The critical care consultations provided via telehealth will use the new Medicare G-codes.

CMS will improve data transparency. Medicare Advantage organizations use a bidding process to apply to participate in the Medicare Advantage program, and the bidding process will reflect the organization’s estimated costs to provide benefits to enrollees. Under the final rule, Medicare Advantage organizations are required to release data associated with these bids on an annual basis. CMS will also require Medicare Advantage organizations and Part D sponsors to release medical loss ratio data on a yearly basis to help beneficiaries make enrollment decisions.

The agency revised the methodology used to calculate geographic practice cost indices. CMS adjusts payments under the physician fee schedule to reflect local differences in practice costs using geographic practice cost indices. The agency will revise the methodology used to calculate GPCIs to increase overall physician fee schedule payments in Puerto Rico. The updates will be phased in over 2017 and 2018.

CMS finalized expansion of the Medicare Diabetes Prevention Program. The 2017 rule finalizes some aspects of the expanded model, but future rulemaking will address payment policies, program safeguards and other issues. CMS expects to begin payment for MDPP services in 2018.

CMS revised the billing codes to more accurately pay for primary care, care management and other cognitive specialties. Among the changes are new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions.

Physician payment rates will increase by 0.24 percent in 2017. CMS arrived at this increase after accounting for a 0.5 percent increase required by the Medicare Access and CHIP Reauthorization Act and mandated budget neutrality cuts, according to the American Hospital Association.

For more information, please see Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year (CY) 2017

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Death vs. Another Hospital Stay: Study Suggests Medicare Should Weigh Them Equally

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Death vs. Another Hospital Stay: Study Suggests Medicare Should Weigh Them Equally

ANN ARBOR — In the last few years, American hospitals have focused like hawks on how to keep patients from coming back within a few weeks of getting out.

Driven by new Medicare penalties for such events, the effort has slowed a ‘revolving door’ of readmissions for heart attack, heart failure and pneumonia patients that costs the nation billions of dollars.

But, a new analysis suggests that Medicare should focus more on how well hospitals do at actually keeping such patients alive during the same time.

If hospitals got paid less when their patients died soon after a hospitalization, just like they get paid less when those patients end up back in the hospital, it would be a game-changer for one-third of hospitals, say researchers from the University of Michigan Medical School and VA Ann Arbor Healthcare System who published their findings in JAMA Cardiology.

According to the study, about 17 percent of hospitals are getting punished for excess readmissions, but are keeping patients alive more often than would be expected, and another 16 percent of hospitals essentially get rewarded for low readmission rates, but their patients are more likely to die in the first month after leaving their hospital beds.

In other words, some of the hospitals that get penalized for high readmissions are those that may actually do the best job at keeping patients alive – and vice versa.

Preventive incentives

If the penalties took both readmission and mortality into account, the Medicare system would save the same amount of money, but incentivize good outcomes more fairly, the researchers said.

“Under most circumstances, hospital patients would much rather avoid death than readmission,” said Scott Hummel, M.D., M.S., senior author of the new paper and a heart failure cardiologist. “But the incentive to prevent death in the first 30 days after a hospitalization is 10 times less than the incentive to prevent a return hospital visit.”

He and his colleagues hope their analysis will spark a conversation about how to fine-tune the Medicare system’s effort to encourage better performance by America’s hospitals.

Their work is based on data from 2014, the first year when hospitals could both be penalized for readmission rates that were higher than expected and earn a financial reward based on a mix of measures that include everything from 30-day death rates to how well patients rated the care they received and the hospital environment.

Under the current policy, hospitals can lose up to three percent of condition-related payments from Medicare for excess readmissions but can recoup only about 0.2 percent of such payments for having low mortality rates.

First author Ahmad Abdul-Aziz, M.D., an internal medicine resident at U-M, helped coordinate the data analysis using publicly available data from the Centers for Medicare and Medicaid Services, called CMS for short. Some of it was accessed via an online system created by Kaiser Health News, based on data from CMS. In all, data from 1,963 hospitals was included.

The authors, who also include senior team members Rodney Hayward, M.D., and Keith Aaronson, M.D., M.S., calculated a ratio for each hospital based on observed and expected readmissions and mortality in the first 30 days for heart attack, heart failure and pneumonia. Although other conditions were added to the readmission program in 2015 and 2016, they weren’t included because these diagnoses are not yet included in the reward program for low mortality rates.

All the data were adjusted for how sick each hospital’s patients were when they started, using standard methods that allow an apples-to-apples comparison. The socioeconomic status of each hospital’s patients, which can also affect patient outcomes but aren’t in a hospital’s control, wasn’t included because CMS hadn’t yet started taking it into account in 2014.

The authors don’t take issue with the idea of penalizing excess readmissions — though they do note that readmissions for any cause are included in the program, not just readmissions for the problem that sent the person to the hospital in the first place.

Admissions to any hospital within 30 days of discharge count against the hospital that the patient was discharged from, which may work against large hospitals that patients travel to for advanced care before returning to their home area.

Other researchers have shown there isn’t a tight link between a hospital’s 30-day readmission rate and the 30-day mortality rate for its patients with these conditions — suggesting that there’s more to the story when thinking about using them as measures of hospital quality.

The authors also call for continued improvement in risk models that will more precisely predict a patient’s risk of readmission, just like current, well-tested models to predict their risk of death.

Better tools would mean better ability to test a hospital’s actual performance against what might be expected based on their entire patient population. The researchers also plan to examine what kinds of hospitals are most likely to win or lose financially if the balance shifts between penalties for reducing readmissions and those for reducing early mortality.

“The misaligned incentives for preventing readmission and preventing death may help explain why some hospitals are doing really well on one, but not on the other,” said Hummel. “It’s important we continue to reduce preventable readmissions, but we need to watch out for unintended consequences too.

“Sometimes, a readmission might be a good thing — no one wants to see patients die because they should have been readmitted,” he added. “If financial penalties drive hospitals to figure out how to improve outcomes, increasing incentives to reduce early post-hospital deaths seems like a good place to start.”

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