Benefits Improvement and Protection Act BIPA Reviews

1
Benefits Improvement and Protection Act (BIPA)
Reviews

• Cathy Bowles, West Virginia Medical
  Institute/Quality Insights

2
Benefits Improvement and Protection Act

• Section 521 of Medicare, Medicaid, and SCHIP
  Benefits Improvement and Protection Act of 2000
  (BIPA)
• Section 1869(b)(1)(F) of Social Security Act
  requires a process by which a beneficiary may
  obtain an expedited determination in response to
  termination of provider services

3
Termination of Services

• Discharge of a beneficiary from a residential
  provider of services
• Complete cessation of coverage at end of a course
  of treatment
• Termination does NOT include a reduction in
  services
• Termination does NOT include exhaustion of
  benefits

4
Settings Affected by the New BIPA Reviews

• Home Health Care Agencies (HHAs)
• Hospices
• Skilled Nursing Facilities (SNFs)
• Comprehensive Outpatient Rehabilitation
  Facilities

5
BIPA Review Process

• QIO must process reviews 7 days a week
• Beneficiary (or representative) must request a
  QIO expedited appeal by Noon of the day prior to
  the effective date (termination date)
• Same day request is received QIO notifies
  Provider

6
BIPA Review Process

• Provider must issue Detailed Notice to
  beneficiary by Close of Business of the day of
  QIOs notification
• Provider must send copy of medical record, copy
  of Advance Notice and copy of Detailed Notice to
  QIO by COB of QIOs notification

7
Provider Responsibility

• Provider must deliver a valid written notice
  (Notice of Medicare Provider Non-Coverage,
  Advance Notice) to Medicare beneficiary
• Must be issued not later than 2 calendar days
  before the proposed end of services
• If services fewer than 2 days in duration, issue
  notice at time of admission
• If non-residential setting Notice must be given
  no later than the next to last time services are
  furnished

8
Provider Responsibility

• Upon request from a beneficiary, Provider must
  furnish the beneficiary with a copy of or access
  to, any documentation that it sends to the QIO
• Burden of proof rests with Provider to
  demonstrate that termination of services is
  correct decision

9
Notice of Medicare Provider Non-Coverage

• Content of Notice
• Date that coverage of service ends (Effective
  date)
• Date financial liability begins
• Description of right to appeal
• Description of right to detailed information
• QIO Contact information

10
Notice of Medicare Provider Non-Coverage

• QIO Contact Information
• Quality Insights of Pennsylvania
  (1.800.322.1914)
• Quality Insights of Delaware (1.866.475.9669)
• West Virginia Medical Institute (1.800.642.8686,
  ext 2266)

11
Valid Notice

• Beneficiary signed and dated notice
• The timing of delivery was appropriate
• The content of the notice is correct
• If beneficiary mentally incompetent deliver
  notice to Legal Representative

12
Invalid Notice

• QIO will inform Provider if a Notice is invalid
• Provider will need to issue a new Notice

13
Notice Delivery

• Beneficiary Refuses to Sign
• Annotate the notice to indicate the refusal
• The date of the refusal is the date of receipt of
  the notice

14
Medicare Beneficiary May Appeal If

• Non-Residential Provider (CORF and HHA)
• Beneficiary disagrees with termination of
  services AND
• Physician certifies that failure to continue the
  services may place the beneficiarys health at
  significant risk

15
Medicare Beneficiary May Appeal If

• Residential Provider (SNF and Hospice)
• Beneficiary disagrees with discharge decision

16
Physician Certification

• Applicable for HHAs and CORFs (ONLY)
• A physician certifies that failure to continue
  the services may place the beneficiarys health
  at significant risk
• If provider has no such statement the QIO will
  ask this question to the QIO Physician Reviewer
• If decision is that the beneficiary would not be
  placed at significant risk beneficiary does not
  have an appeal right

17
Detailed Notice Content

• Detailed explanation why services are no longer
  necessary or covered
• Description of any applicable Medicare coverage
  rules, other Medicare policy rules or information
  about how to obtain a copy of the Medicare policy

18
Detailed Notice Content

• Facts specific to the beneficiary and relevant to
  coverage determination that are sufficient to
  advise the beneficiary of the applicability of
  the coverage rule or policy to the beneficiarys
  case
• Any other information required by CMS

19
Responsibility of QIO

• Immediately notify provider of appeal request
• Determine if Advance Notice is valid
• Review medical record and other information
• Includes physician certification for HHA and CORFs

20
Responsibility of QIO

• Make determination within 72 hours from receipt
  of an expedited appeal request
• Determination Whether termination of Medicare
  coverage is the correct decision

21
Responsibility of QIO

• Notify the beneficiary (or representative),
  beneficiarys physician, and provider of decision
• Initial notification will be made by telephone
• Written notification will follow

22
Responsibility of QIO

• Written notification will include
• Rationale for decision
• Date beneficiary becomes financially liable
• Information about the beneficiarys right to a
  reconsideration
• How to request a reconsideration

23
Untimely Requests

• If request for appeal is not made timely (later
  than Noon the day before effective date) QIO will
  make decision as soon as possible
• 72 hour timeframe for completing review does NOT
  apply

24
Medicare BeneficiaryReconsideration Request

• If beneficiary disagrees with QIO determination,
  he/she may request a reconsideration
• Only the beneficiary (or representative) may ask
  for a reconsideration
• Reconsideration will be preformed by the
  Qualified Independent Contractor (QIC)

25
Coverage of Provider Services

• Coverage continues until the date on the Advance
  Notice, unless the QIO or QIC reverses the
  providers termination decision
• Providers are not to bill beneficiary for any
  disputed services until expedited review and
  reconsideration review (if applicable) is
  completed

26
Coverage of Provider Services

• If the QIOs 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
• If the Advance Notice is considered invalid,
  coverage continues until two calendar days after
  a valid notice has been received

27
Timing of Process
28
Website For Notices

• www.cms.hhs.gov/regulations/pra
• Scroll down page to date of April 29, 2005
• Click on rev cms10123-10124.zip 171 KB
• 10123genericnot Advance Notice
• 10124detailedno Detailed Notice

29
QIO Contact Information

• Patti Johnson, Quality Insights of Pennsylvania
• 1.877.346.6180, ext 7628
• Email pjohnson_at_wvmi.org
• Anita Ciconte, Quality Insights of Delaware,
• 302.478.3600, ext 107
• Email aciconte_at_wvmi.org
• Cathy Bowles, West Virginia Medical Institute,
  304.346.9864, ext 4256
• Email cbowles_at_wvmi.org

30
Questions

• This material was prepared by Quality Insights of
  Pennsylvania, the Medicare Quality Improvement
  Organization for Pennsylvania, under contract
  with the Centers for Medicare Medicaid Services
  (CMS). The views presented do not necessarily
  reflect those of CMS. Publication number
  7SOW-PA-REV05.64