1. Medicare Quality Improvement Organization (QIO) Reviews Under the Benefits Improvement and Protection Act §521 Presented by Alabama Quality Assurance Foundation 2005

2. Benefits Improvement and Protection Act (BIPA) §521 Federal Register, Friday, November 26, 2004  42 CFR 405.1200-1206  To locate: http://www.gpoaccess.gov/frhttp://www.gpoaccess.gov/fr  Select Advanced (1994-2005)  Select Volume 2004 FR, Vol. 69  Select Section: Final Rules & Regulations  Specific Date On: 11/26/2004  Search: “42 CFR.405”  Click Submit  Click Medicare Program; Expedited Determination Procedures for Provider

3. Benefits Improvement and Protection Act (BIPA) §521 Section 521 of the Medicare, Medicaid and SCHIP Benefits Improvement Act of 2000 (BIPA), amended section 1869 of the SSA (the Act) to require significant changes to the Medicare appeals procedures.

4. Benefits Improvement and Protection Act (BIPA) §521 The Act required establishment of a process by which a beneficiary may obtain an expedited determination in response to the termination of provider services.

5. Affected Health Care Providers Home Health Agencies (HHAs) Hospices Skilled Nursing Facilities (SNFs) Comprehensive Outpatient Rehabilitation Facilities (CORFs)

6. Termination of Medicare- Covered Services Discharge from a residential provider (ending of skilled services) Complete cessation of coverage at the end of a course of treatment

7. Provider Responsibility Medicare Beneficiary’s Right Advance written notice of service terminations:  Before any termination of services, the provider must deliver a valid written notice to the beneficiary of the decision to terminate services.

8. Provider Responsibility Medicare Beneficiary’s Right Termination does not include a reduction in services. Does not include the termination of one type of service by the provider if the beneficiary continues to receive other Medicare-covered services from the provider.

9. Provider Responsibility Medicare Beneficiary’s Right The new expedited determination process at 69 Fed. Reg. 69252 (Nov. 26, 2004) governs all terminations of previously covered HHA services.

10. Provider Responsibility Timing of Notice Delivery Issued not later than two calendar days before the proposed end of the services If services are fewer than two days in duration, the notice should be issued at the time of admission

11. Provider Responsibility Timing of Notice Delivery If, in a non-residential setting, the span of time between services exceeds two days, the notice must be given no later than the next to last time services are furnished.

12. Provider Responsibility Content of Advance Notice Date that coverage of service ends Date beneficiary’s financial liability begins Description of right to appeal Description of right to detailed information Any other information required by CMS

13. Provider Responsibility Valid Notice Beneficiary signed and dated notice The timing of delivery was appropriate The content of the notice is correct

14. Provider Responsibility Beneficiary Refuses to Sign Annotate the notice to indicate the refusal The date of the refusal is the date of receipt of the notice

15. Financial Liability The provider is liable for continued services until two calendar days after the beneficiary receives a valid notice, or until the service termination date (effective date), whichever is later.

16. Medicare Beneficiary May Appeal If Non-residential provider (HHA/CORF)  Beneficiary disagrees with termination of service and  Physician certifies that failure to continue the service may place the beneficiary’s health at significant risk

17. Medicare Beneficiary May Appeal If Residential provider (SNF) or hospice  Beneficiary disagrees with discharge decision

18. Medicare Beneficiary Appeal Request The beneficiary (or representative) must request a QIO expedited appeal by noon of the day prior to termination of service(s).

19. Medicare Beneficiary Untimely Appeal If a valid notice was issued, a non- expedited QIO review is performed  Make a decision “as soon as possible”

20. Provider Responsibility Expedited Review Send detailed notice to the beneficiary by close of business of the day of the QIO’s notification

21. Provider Responsibility Detailed Notice Content Specific and detailed explanation why services are either no longer reasonable and necessary or are no longer covered

22. Provider Responsibility Detailed Notice (continued) Description of any applicable Medicare coverage rules, instruction, or other Medicare policy rules or information about how the beneficiary may obtain a copy of the Medicare policy

23. Provider Responsibility Detailed Notice (continued) Facts specific to the beneficiary and relevant to the coverage determination that are sufficient to advise the beneficiary of the applicability of the coverage rule or policy to the beneficiary’s case Any other information required by CMS

24. Provider Responsibility Information to QIO Supply all information, including a copy of the advance and detailed notices  For expedited appeals, this information should be furnished not later than by close of business of the day the QIO notified the provider of the appeal

25. Provider Responsibility Information to QIO The provider may be held financially liable in continued coverage if a delay results from the provider failing to supply requested information in a timely manner

26. Responsibility of the QIO Expedited Review Immediately notify provider of appeal request Determine if notice is valid Examine medical and other records pertaining to services in dispute  Includes, if applicable, physician certification

27. Responsibility of the QIO Expedited Review Within 72 hours from receipt of an expedited appeal request, the QIO must make a determination on whether termination of Medicare coverage is the correct decision

28. Responsibility of the QIO Determination Notify the beneficiary (or representative), beneficiary’s physician, and the health care provider  Initial notification may be made by telephone  A written notification must follow

29. Responsibility of the QIO Written Notification Rationale for determination Explanation of the Medicare payment consequences and the date the beneficiary becomes fully liable for services Information about reconsideration rights, including how to request and the time period

30. Medicare Beneficiary Reconsideration Request If the beneficiary disagrees with the QIO’s initial appeal determination, he or she may request a reconsideration.  Only the beneficiary (or representative) may ask for a reconsideration

31. Medicare Beneficiary Reconsideration Request Qualified Independent Contractors (QIC) will perform reconsiderations.

32. ALJ Review Request QICs will prepare cases for ALJ review

33. Coverage of Provider Services Coverage continues until the date and time designated on the termination notice, unless the QIO or QIC reverses the provider’s service termination decision

34. Coverage of Provider Services (continued) Do not bill the beneficiary for any disputed services until the expedited determination process (and reconsideration process, if applicable) has been completed.

35. Coverage of Provider Services (continued) If the QIO’s decision is delayed because the provider did not timely supply necessary information or records, the provider may be liable for costs of any additional coverage.

36. Coverage of Provider Services (continued) If the QIO determines that the beneficiary did not receive a valid notice, coverage of provider services continues until at least two calendar days after a valid notice has been received.

37. Provider Responsibility Releasing Information to Beneficiary At a beneficiary’s request, the provider must furnish the beneficiary with a copy of, or access to, any documentation that it sends to the QIO.

38. AQAF Contacts 1-800-760-4550 Pam Taylor, Beneficiary Protection Program Leader, ext. 3512 Joan Wilder, Review Coordinator, ext. 3218 Barbara Baites, Review Coordinator, ext. 3228 Anita Meyers, Review Coordinator, ext. 3217 Laura Rutledge, Review Coordinator, ext. 3429 Cathy Dixon, Review Coordinator, ext. 3426

39. Questions?

40. HOW DOES ALL OF THIS WORK?

41. REFERENCES cms.hhs.gov/regulations/pra cms.hhs.gov/medicare/bni MedLearn CMS Provider ListServe

42. BIPA Appeals Number AQAF’s Appeals Hotline #: – 1-800-366-1486 Insert this number on the notice

43. Alabama Quality Assurance Foundation This material was prepared by Alabama Quality Assurance Foundation (AQAF), the Medicare Quality Improvement Organization for Alabama under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health & Human Services. The contents presented do not necessarily reflect CMS policy. 7SOW-AL-GEN-05-34