In the midst of tremendous challenges facing the hospice industry, the Centers for Medicare and Medicaid Services (CMS) has issued guidance to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) that is likely to have a positive effect on hospice providers.  The guidance from CMS directs MAC and QIC reviewers to limit the redetermination and reconsideration review to the reason(s) the claim was initially denied for all post-payment reviews.

The updated guidance from CMS applies to all post-payment redetermination or reconsideration appeal requests received by the MAC or QIC on or after August 1, 2015; however, the guidance will not be applied retrospectively.  This recent CMS guidance will also not apply to claims being reviewed on a pre-payment basis by the MAC or QIC.

Background

In the past, MACs and QICs had a great deal of discretion when conducting clinical record reviews for redetermination and reconsideration appeal.  During past post-payment appeal reviews, the MAC or QIC reviewer could review all aspects of coverage and payment and develop new issues (i.e., reason(s) for claim payment denial) regardless of whether a prior MAC reviewer identified the issue or if the hospice provider “cured” the reason for the prior claim denial.

Example (Historical MAC/QIC Review):

Sample Hospice submitted clinical records for an Additional Development Request (ADR) for a patient’s May 2015 dates of service.  Unfortunately, Sample Hospice failed to include the Face-to-Face Encounter (F2FE) visit documentation associated with the benefit period from 04/10/15 through 06/08/15; therefore, the MAC issued a technical claim payment denial.

Sample Hospice submitted a redetermination appeal request and submitted the F2FE visit note related to the aforementioned denial.

The MAC redetermination reviewer reviewed all aspects of coverage and payment and acknowledged the presence of the F2FE visit note. However, the reviewer determined that the clinical record documentation did not support the patient’s terminal prognosis; therefore, the MAC issued a payment denial of the redetermination appeal.

Example (with new CMS guidance applied):

Sample Hospice submitted clinical records for an ADR for a patient’s May 2015 dates of service.  Unfortunately, Sample Hospice failed to include the F2FE visit documentation associated with the benefit period from 04/10/15 through 06/08/15; therefore, the MAC issued a technical claim payment denial.

Sample Hospice submitted a redetermination appeal request and submitted the F2FE visit note related to the aforementioned denial.

The MAC redetermination reviewer acknowledged the presence of the F2FE (the reason for the previous denial) in the clinical record documentation and issues a favorable decision for payment.

What You Need to Do

Although the recent CMS guidance will likely benefit hospice providers during redetermination and reconsideration appeals, a timely and organized response to the initial ADR request is still essential in seeking a positive payment determination from the MAC. The following are some suggestions for ADR response:

Ensure you submit all requested ADR documentation to the MAC on time.  Failure to do so will result in an automatic claim denial;

When sending clinical record documentation to the MAC, request delivery receipt confirmation (to serve as documentary evidence of a timely submission);

Consider including a summary cover letter (created internally or by an independent expert reviewer like Weatherbee Resources) with each clinical record;

Organize the clinical record to the greatest extent possible. Consider including a table of contents that directs the reviewer to all pertinent technical and clinical record documentation elements; and

Have an internal validation process (prior to submitting the clinical record to the MAC) to ensure the inclusion of all requested elements.

Conclusion

As stated previously, CMS’ guidance regarding post-payment redetermination and reconsideration appeals is a move in the right direction that will likely benefit the hospice industry; however, the goal of all hospice organizations should be to obtain a positive claim determination at the ADR level and not be dependent on a good outcome at the redetermination and/or reconsideration appeal levels based on the new guidance from CMS.  In order to do this, the hospice must ensure that (1) all technical elements (e.g., certification/recertification of terminal illness, Physician Narrative, Face-to-Face encounter, etc.) are valid and  (2) clinical record documentation supports the patient’s terminal prognosis throughout the dates of service under review.

If anyone has any recommended practices related to ADRs or appeals, feel free to share them in the “Comments” section so that all may benefit.

Resources:

“Limiting the Scope of Review on Redeterminations and Reconsiderations of Certain Claims” Medicare Learning Network (MLN). MLN Matters SE 1521. September 2015.

Posted by Carrie Cooley, RN, MSN – Chief Operating Officer of Weatherbee Resources, Inc.