MAXIMUS

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MAXIMUS
Medicare Choice Appeals Conference Grijalva
More MAXIMUS Center for Health Dispute Resolution

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MAXIMUS CHDR
Medicare Managed Care Reconsideration Project

• New at MAXIMUS CHDR
• Working with MAXIMUS CHDR
• Appeals Data

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MAXIMUS CHDR
Whats New

• ISO 90012000 Certified
• New Manual
• New Website

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MAXIMUS CHDR
Quality Policy
All staff and suppliers to MAXIMUS CHDR
understand and meet or exceed, customer
requirements so as to provide timely, unbiased,
expert, medical insurance appeal determinations,
thereby assisting our government clients to
better serve the people.
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ISO 90012000
What is it?

• Internationally recognized quality management
  system standard
• Developed by International Organization of
  Standardization
• Emphasizes quality standards in
• systems
• procedures
• documentation

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ISO 90012000
What does certification mean?

• MAXIMUS CHDR subject to audit conducted by
  outside independent auditor.
• Independent auditor determines whether the
  procedures, practices and quality systems meets
  the defined ISO standards.
• MAXIMUS CHDR passed initial audit with no
  findings
• Periodic re-certification

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ISO 90012000
Why do it?

• Staff involvement
• Opportunities to identify areas for improvement
  and systems to evaluate the solutions
• Improve and refine prior quality management
  systems
• Contractual requirement

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ISO 90012000
Impact on Medicare Managed Care Reconsideration
Project

• Decision Processing
• Appeal Officers
• Independent Physician Consultants
• Internal Audit

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ISO 90012000
Decision Processing

• Documented MAXIMUS CHDR appeal processing
• Internal time goals for decision processing steps
• Appeal Officer Attestation
• Increased Quality Reviews

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ISO 90012000
Appeal Officer

• Created specialized teams
• Attestation
• Team Leaders
• Over 30 years combined experience
• Monitor timeliness/processing/quality
• Quality Reviews
• Increased sample size on monthly basis for each
  team member
• Internal Quality Control Monitoring Tool used to
  capture and measure

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ISO 90012000
Independent Physician Consultant

• Structured medical review instrument, with
  attestation
• Verified assessment of medical reviewers cases
  by 1st level reviewer
• Review by Medical Director or peer of
  questionable medical reviewer determinations

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ISO 90012000
Independent Physician Consultant

• Review of new medical reviewers cases by Medical
  Director or peer until production of two
  error-free reviews in a row
• Sampling of at least five percent of decisions on
  an annualized basis
• Documented real time feedback to reviewers for
  corrective action (for example, re-education)

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ISO 90012000
Internal Audits

• ISO 9001-2000 requires an effective and
  continuous system of internal audits
• Operates as a self-check on the Quality
  Management System and operation
• Non-conformances and observations are used to fix
  or improve procedures
• Collection and analysis of the results by
  management helps improve effectiveness and
  efficiency

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ISO 90012000
Customer Contact

• Customer defined as CMS, Medicare managed care
  plans and enrollees
• MAXIMUS CHDR welcomes comments, suggestions and
  feedback
• Continuous cycle of feedback, evaluation,
  improvement

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New MC Reconsideration Process Manual

• Effective January 2003
• Includes information on
• How to contact MAXIMUS CHDR
• Considerations for development
• How to submit case file to MAXIMUS CHDR
• MAXIMUS CHDR Reconsideration Process
• New data collection efforts
• New decision letters

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Medicare Managed Care Reconsideration Project Web
Site
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Medicare Managed Care Reconsideration Project Web
Site

• Located at www.medicareappeal.com
• Pages for enrollees, health plans, researchers
• Case status search
• Updated daily (1.5 day lag from case
  receipt/action)
• Search by case number or plan contract number
• Problems with web site? Contact us at
  medicareappeal_at_maximus.com

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Medicare Managed Care Reconsideration Project Web
Site
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Working with MAXIMUS CHDR

• Reconsideration Background Data Form
• Case file submission
• Submitting additional information
• Reopening requests
• Data Reports

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Working with MAXIMUS CHDR
Reconsideration Background Data Form

• Common Issues
• Case Class
• Processing Dates
• Impact on Data Reports to CMS

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Working with MAXIMUS CHDR
Reconsideration Background Data Form Common Issues

• Enrollee Medicare
• Validate Enrollment
• Incorrect number delays case initiation
• Plan Contract
• Validate MCO
• Compliance Reporting
• Recycled Forms Representative Issues
• Case Class

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Working with MAXIMUS CHDR
Reconsideration Background Data Form Case Class

• Expedited
• Standard Service
• Item/service in appeal has not yet been given to
  Enrollee
• Past and future services
• Standard Claim
• Enrollee received item/service in appeal
• Reimbursement only

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Working with MAXIMUS CHDR
Reconsideration Background Data Form Plan
Processing Dates

• Section VI(A) - Organization Determination
  Processing Dates
• Section VI(B) Reconsideration Determination
  Processing Dates
• Date of valid appeal request
• Date of decision by Plan

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Working with MAXIMUS CHDR
Reconsideration Background Data Form Impact on
Data Reports

• Plan Identification
• Plan Processing Timeliness
• MAXIMUS CHDR reports Plan timeliness using
  reconsideration dates provided on Reconsideration
  Background Data Form
• MAXIMUS CHDR separately captures discrepancy data

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Working with MAXIMUS CHDR
Reconsideration Background Data Form Correcting
Plan Error

• Corrections before report provided to CMS
• Do not send in new RBDF
• Provide information in writing to MAXIMUS CHDR
• Retain in file
• After timeliness report provided to CMS
• Send information to MAXIMUS CHDR and CMS
• MAXIMUS CHDR will not change data
• MAXIMUS CHDR will not re-run reports

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Working with MAXIMUS CHDR
Reconsideration Background Data Form Correcting
MAXIMUS CHDR Error

• Send written notice to MAXIMUS CHDR
• MAXIMUS CHDR will research and report back to the
  Plan and CMS any errors made in recording data
• MAXIMUS CHDR will correct data errors
• MAXIMUS CHDR will not re-run report

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Working with MAXIMUS CHDR
Submitting New Case File

• Must include completed Reconsideration Background
  Data Form
• Please place divider or otherwise separate
  multiple cases submitted in one package
• Expedited Cases submit NOI via fax only
• MAXIMUS CHDR will not accept cases sent via
  facsimile

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Working with MAXIMUS CHDR
Submitting Additional Information

• Include case number and enrollee name
• Do not re-send Reconsideration Background Data
  Form as part of additional information submission
• Do not send medical records via facsimile

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Working with MAXIMUS CHDR
Reopening Requests

• Make reopening request in writing
• Not an automatic appeal for OT decisions
• Only granted when
• Error on the face of the evidence,
• New information not previously available, or
• Fraud

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Working with MAXIMUS CHDR
MAXIMUS CHDR Enhanced Data Collection

• Plan processing discrepancies
• Actual document (e.g. appeal letter, denial
  notice)
• RBDF
• Case narrative
• Organization Determination Notice
• Plan denial and decision reasons
• Enrollee arguments

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Working with MAXIMUS CHDR
Data Reports

• Monthly Reports
• Appeal receipt volume
• Data on disposition of completed cases
• Quarterly Reports
• Plan timeliness
• Compliance Reports
• Annual Reports
• Available through www.medicareappeal.com

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Working with MAXIMUS CHDR
Quarterly Reports Plan Processing Timeliness

• Interval reported based on MCO supplied
  information in Reconsideration Background Data
  Form and date of case receipt
• Standard appeal cases assume 5 day period for
  mailing
• Expedited cases assume 1 day period for mailing

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Working with MAXIMUS CHDR
Quarterly Reports Compliance Reports

• Identifies whether MAXIMUS CHDR has received
  compliance statement for OT cases
• Notice sent to Plan by MAXIMUS CHDR
• Notice gives plan approx. 2 weeks to correct
  before reported to CMS

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Working with MAXIMUS CHDR
Quarterly Reports Compliance Reports Helpful
Hints

• Use Statement of Compliance included in OT
  decision
• Can send Statement of Compliance by fax
• MAXIMUS CHDR does not accept questionable
  compliance statements such as planning to
  authorize
• MAXIMUS CHDR will send questionable compliance
  statements to CMS RO

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Appeals Data
Number of Cases Received Nation

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Appeals Data
Number of Cases Received Regions 8, 9 10

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Appeals Data
Cases Received Case Class Nation

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Appeals Data
Cases Received Case Class Regions 8, 9 10

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Appeals Data
Comparing Rate of OT for 2003

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Appeals Data

Overturns by Category Regions 8, 9 10