A years-long frustration on the part of Medicare-certified healthcare at home providers has ended. It has always been the case that you are able to appeal a claim denial if you believe your Medicare Administrative Contractor incorrectly refused or adjusted your payment. Without incurring too much expense, you wrote a letter and perhaps provided some supporting evidence, asking the MAC to reconsider but, 99 percent of the time, they "reconsider" and respond, "nope, we were right the first time."
That's not the frustration.
Should you decide to pursue your appeal, which you always should just to keep them honest, you are allowed to escalate your reconsideration request from your MAC to a Qualified Independent Contractor. Historically, this has been a problem. QICs have always been in the habit of denying your appeal in nearly every case but not always for the same reason the MAC cited.
This is the frustration. They declare, "The MAC was wrong to deny your payment but we have found a different reason, and it is still denied."
As of August 1 of this year, this practice ended. In Medicare Learning Network Matters #SE1521, CMS informed physicians and other care providers that they have instructed QICs that they may no longer pivot to a new denial reason when they determine that the original denial reason is unsupported by the evidence. This instruction will apply whether the QIC is asked to redetermine a denial that was originally imposed by a MAC, a Zone Program Integrity Contractor, a Recovery Audit Contractor, or a Comprehensive Error Rate Testing contractor. (ZPIC, RAC, CERT)
This is big news. It has the potential to accelerate cash flow and reduce your expenses associated with preparing appeals. Providers of in-home services to Medicare beneficiaries have long suspected that QICs decide first that a claim will be denied, then look around afterward for a reason to support their decision. They also suspect that QICs are either paid on commission or are given a denial quota by CMS. Whether either of those is true cannot be learned by asking anyone within CMS but no one can deny that the QIC track record — over 95% of the time rubber-stamping the MAC's denial, with or without the same justification — generates suspicion.
A careful reading of the MLN Matters article (reprinted below) reveals that only cases where the payment has been denied are subject to this new instruction. If you win your appeal, presumably in response to your initial redetermination request, and your claim is paid, the QIC is free to look for new reasons to deny or reduce your payment. Look for the paragraph that begins, "Please note that contractors will continue to follow existing procedures regarding claim adjustments resulting from favorable appeal decisions."
MLN Matters® Number: SE1521
Provider Types Affected
What You Need to Know
©2015 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org