BIPA/New Medicare Appeals 7/01/05

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BIPA/New Medicare Appeals7/01/05

• Presenter
• Monica Batton, RN Review Manager
• Delmarva Foundation for Quality Improvement
• 1-800-492-5811

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BIPA

• BIPA stands for
• Benefits Information Protection Act 521
• 42CFR Friday, November 26, 2004 405.1200-1206
• Posted on our website at http//www.delmarvafounda
  tion.org/bipa/

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Providers affected by the new law

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

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How does the new act affect you as providers?

• Medicare Part A services are affected
• The appeal right pertains to fee for service
  Medicare Beneficiaries

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Materials Available

• http//www.delmarvafoundation.org/bipa/
• Federal Register, Glossary, List of related
  websites, timing of notices example, and a link
  to Delmarva webex recordings
• 1-800-492-5811 help line provided by Delmarva for
  Beneficiaries and appeals

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Memorandums of Agreement

• CMS, Center for Medicare and Medicaid Services
  requires that we as their contracted Quality
  Improvement Organization for Maryland and the
  District of Columbia maintain Memorandums of
  Agreements, (MOAs) with healthcare providers
  that we interact with

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Memorandums of Agreement continued-

• Delmarva Foundation presently has MOAs with HHA,
  SNFs, and CORFs.
• Delmarva Foundation has sent out MOAs for
  review, signature, and return to all Maryland and
  District of Columbia Hospices

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Termination of Medicare Covered Services

• Termination of Medicare services is done when
  they are discharged from a provider
• This occurs when there is complete cessation of
  coverage at the end of the course of treatment.
  (refer to CMS manual for your agency and
  definition)

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Provider Responsibility

• Before any termination of services, the provider
  must deliver a valid written notice to the
  beneficiary of the decision to terminate
  services. Mailing the notice does not meet the
  requirement for BIPA.

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Timing of Notice

• A notice must be issued not later then two
  calendar days before the proposed end of the
  services.
• Home Health must be delivered two visits before
  the proposed end of services.
• If services are fewer than two days in duration,
  the notice should be issued at the time of
  admission.

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Where can you find coverage information?

• We posted a list of website links to CMS manuals
  that will give you this information for your
  provider setting.

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Where can you find an example of a Notice?

• We provided a website link on our list of
  websites that will give you a draft notice
  example. It has not been finalized by CMS at the
  time of this webex.

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Content of the Generic Notice

• Date that coverage service ends
• Date of beneficiarys financial liability begins
• Description of right to appeal
• Description of right to detailed information
• Any other information required by CMS
• Delmarva contact information

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Valid Generic Notice

• The content of the notice including dates and
  financial liability is correct.
• Beneficiary signed and dated the notice
• The notice was delivered within appropriate
  timeframe.

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Notice DeliveryWhat if beneficiary refuses to
sign?

• Note the refusal of the beneficiary to sign on
  the notice.
• The date of the refusal is the date of receipt of
  the notice.
• The notices cant be mailed to the beneficiary.
• 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, whichever is later.

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When can the Medicare Beneficiary appeal

• CORFs and HHAs
• When the beneficiary disagrees with termination
  of service
• When a physician determines that failure to
  continue the service may place the beneficiarys
  health at significant risk

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When can the Medicare Beneficiary appeal

• SNFs and Hospice
• When the beneficiary disagrees with the discharge
  decision

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How does the beneficiary request an appeal?

• The beneficiary (or representative) must request
  a QIO expedited appeal by calling Delmarva
  Foundation by noon of the day prior to
  termination of service at our 800 number listed
  at the beginning of the slide presentation.
  1-800-492-5811

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Example of Appeal Timelines

• Provider issues a notice on 6/1/05 stating that
  services will end on 6/3/05
• The beneficiary needs to call the Delmarva
  Foundation to request an appeal by 12Noon of
  6/2/05
• The Delmarva Foundation will notify the provider
  that the beneficiary has requested an appeal and
  that the provider needs to issue the detailed
  notice

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Detailed Notice Timeline

• The provider is required to issue the detailed
  notice by close of business of the day Delmarva
  notifies you that the beneficiary requested an
  appeal.

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Untimely Appeal Request

• If a valid notice was issued, the Delmarva
  Foundation is required to perform the review.

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Detailed Notice Content

• The detailed notice must contain specific and
  detailed explanation why services are either no
  longer reasonable and necessary or are no longer
  covered.
• The detailed notice must include a 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.

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Detailed Notice Content continued

• The detailed notice must provide 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 beneficiarys case

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What the Provider needs to supply to Delmarva
Foundation

• Supply all parts of the medical record per
  discussion with Delmarva Foundation at the time
  of the appeal and include a copy of the generic
  notice and the detailed notice.

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What happens if there is a delay in getting
information to the Delmarva Foundation?

• 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.

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What happens once Delmarva Foundation completes
the review?

• Delmarva Foundation will notify the beneficiary,
  beneficiarys physician, and the health care
  provider.
• Initial notification will be by phone
• Written notification will follow.

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What happens if the beneficiary disagrees with
the Delmarva Foundations decision?

• If the beneficiary disagrees with Delmarvas
  decision, the beneficiary may request a
  reconsideration of the decision.
• Delmarva Foundation will then instruct the
  beneficiary to call Maximus.

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When does coverage stop?

• Coverage continues until the date designated on
  the termination notice, unless the Delmarva
  Foundation reverses the providers service
  termination decision

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Billing

• Do not bill the beneficiary for any disputed
  services until the expedited appeal determination
  process and reconsideration process if applicable
  has been completed.
• The Delmarva Foundation only does the medical
  review. The Delmarva Foundation does not handle
  the billing.

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Billing Questions

• You should contact the FI for billing questions.

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Releasing Information to the beneficiary

• If the beneficiary requests, the provider must
  furnish the beneficiary with a copy of or access
  to any documentation that it sends to the
  Delmarva Foundation.

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Delmarva Foundation1-800-492-5811

• Monica Batton, RN
• Review Manager
• 410-763-6287
• mbatton_at_dfmc.org