Improvements to the Medicare Advantage Appeal and Grievance

Procedures

Presented by Presented by

Alabama Quality Assurance Foundation Alabama Quality Assurance Foundation 20052005

Grijalva v. Shalala

This is a 1993 class action lawsuit brought by This is a 1993 class action lawsuit brought by beneficiaries enrolled in the Medicare risk-based beneficiaries enrolled in the Medicare risk-based managed care organization program.managed care organization program.

It challenged the adequacy of the managed care It challenged the adequacy of the managed care appeals process.appeals process.

A settlement agreement was approved by the A settlement agreement was approved by the Arizona District Court on December 4, 2000.Arizona District Court on December 4, 2000.

Grijalva v. Shalala

A key element of the agreement was that A key element of the agreement was that CMS would propose to establish an CMS would propose to establish an independent review entity to conduct fast-independent review entity to conduct fast-track reviews of appeals of decisions to track reviews of appeals of decisions to terminate services.terminate services.

The final rule was published on April 4, The final rule was published on April 4, 2003.2003.

Grijalva v. Shalala

CMS determined that Quality Improvement CMS determined that Quality Improvement Organizations (QIOs) will conduct these reviews Organizations (QIOs) will conduct these reviews because they have the necessary health care because they have the necessary health care reviewers to make these medical necessity reviewers to make these medical necessity decisions.decisions.

QIOs also have extensive experience with this QIOs also have extensive experience with this type of review process through their similar type of review process through their similar responsibilities when Medicare beneficiaries responsibilities when Medicare beneficiaries dispute hospital discharge decisions.dispute hospital discharge decisions.

Grijalva v. Shalala

Effective January 1, 2004, all enrollees who Effective January 1, 2004, all enrollees who are notified of their impending termination are notified of their impending termination of services or discharge from a provider of of services or discharge from a provider of service may appeal directly to an service may appeal directly to an independent review entity, i.e., the independent review entity, i.e., the Medicare QIO.Medicare QIO.

Termination of Service Coverage

Termination occurs when the MA Termination occurs when the MA organization decides to discontinue organization decides to discontinue coverage of services currently being coverage of services currently being provided to an MA enrollee.provided to an MA enrollee.

MA Enrollee’s Right

All MA enrollees have the right to request a All MA enrollees have the right to request a QIO fast-track review to appeal the MA QIO fast-track review to appeal the MA organization’s decision to terminate organization’s decision to terminate coverage of services.coverage of services.

Settings Affected by the New Appeal Rights

Home Health Agencies (HHAs)Home Health Agencies (HHAs)

Skilled Nursing Facilities (SNFs)Skilled Nursing Facilities (SNFs)

Comprehensive Outpatient Rehabilitation Comprehensive Outpatient Rehabilitation Facilities (CORFs)Facilities (CORFs)

Home Health Agency

An organization that provides health care An organization that provides health care services in the homeservices in the home

Services such as skilled nursing care, Services such as skilled nursing care, physical therapy, occupational therapy, physical therapy, occupational therapy, speech therapy, and care by home speech therapy, and care by home health aideshealth aides

–Home Health Aide services are Home Health Aide services are not skilled services.not skilled services.

Skilled Nursing Facility

A facility that provides skilled care servicesA facility that provides skilled care servicesSkilled care requires the skills of Skilled care requires the skills of

qualified technical or professional qualified technical or professional health personnel such as registered health personnel such as registered nurses, licensed practical (vocational) nurses, licensed practical (vocational) nurses, physical therapists, nurses, physical therapists, occupational therapists, and speech occupational therapists, and speech pathologists or audiologists.pathologists or audiologists.

Skilled Nursing Facility

Do not notify patients that services are not Do not notify patients that services are not covered by Medicare because of “rules of covered by Medicare because of “rules of thumb” such as lack of restoration potential, thumb” such as lack of restoration potential, ability to walk a certain number of feet, ability to walk a certain number of feet, degree of stability, or because of general degree of stability, or because of general inferences about patients with similar inferences about patients with similar diagnoses or general data related to diagnoses or general data related to utilization. utilization.

Skilled Nursing Facility

A decision as to whether care is covered by A decision as to whether care is covered by Medicare must be made based on thorough Medicare must be made based on thorough analysis of the patient’s total condition and analysis of the patient’s total condition and individual need for care.individual need for care.

Comprehensive Outpatient Rehabilitation Facility

A facility that provides a variety of A facility that provides a variety of outpatient servicesoutpatient services

For example, physical therapy, social For example, physical therapy, social or psychological services, and or psychological services, and rehabilitationrehabilitation

Notice of Medicare Non-Coverage

Issued by the health care provider, this Issued by the health care provider, this notice:notice:

Contains the patient’s name, Medicare Contains the patient’s name, Medicare number, and the date services will endnumber, and the date services will end

Provides standardized information on a Provides standardized information on a patient’s appeal rights and instructions patient’s appeal rights and instructions on how to initiate an appeal, if on how to initiate an appeal, if necessarynecessary

Notice of Medicare Non-Coverage

Prior to an MA terminating coverage of a Prior to an MA terminating coverage of a service, the provider will be required to deliver service, the provider will be required to deliver an advance notice to the MA enrollee.an advance notice to the MA enrollee.

Intent of advance notice is to inform the Intent of advance notice is to inform the patient of an end date for MA coverage of patient of an end date for MA coverage of the health care service being provided, the health care service being provided, allowing time for an appeal if the patient allowing time for an appeal if the patient disagrees with the coverage end date.disagrees with the coverage end date.

Notice of Medicare Non-Coverage

Advance notice may be given as soon Advance notice may be given as soon as the termination (effective) date is as the termination (effective) date is known; however, it must be given known; however, it must be given no no later than two dayslater than two days before the before the proposed end of the services.proposed end of the services.

If the services are expected to be fewer If the services are expected to be fewer than two days in duration, the patient than two days in duration, the patient must be notified at the time of must be notified at the time of admission.admission.

Notice of Medicare Non-Coverage

Given, even if enrollee agrees that Given, even if enrollee agrees that services should end.services should end.

Not to be used when the MA Not to be used when the MA organization determines that an organization determines that an enrollee’s services should end based on enrollee’s services should end based on the exhaustion of Medicare benefits.the exhaustion of Medicare benefits.

Fast-Track Appeal

The enrollee (or representative) must The enrollee (or representative) must request a QIO Fast-Track Appeal by no request a QIO Fast-Track Appeal by no later than noon the day before the effective later than noon the day before the effective date the Medicare coverage ends.date the Medicare coverage ends.

If timeline is not met, enrollee must If timeline is not met, enrollee must appeal with the MA organization.appeal with the MA organization.

Fast-Track Appeal QIO will inform the MA organization and provider of QIO will inform the MA organization and provider of

the review requestthe review requestQIO, MA organization, and provider must be QIO, MA organization, and provider must be

available to process appeals 7 days/week and available to process appeals 7 days/week and holidays, during business hours (8-4:30PM).holidays, during business hours (8-4:30PM).

If valid advance notice, the QIO will instruct the If valid advance notice, the QIO will instruct the MA organization to issue the detailed notice.MA organization to issue the detailed notice.

MA organization must submit copies of the MA organization must submit copies of the medical record andmedical record and the detailed notice to the the detailed notice to the QIO.QIO.

Fast-Track Appeal

QIO must make a decision on an appeal and QIO must make a decision on an appeal and notify the enrollee, the MA organization, notify the enrollee, the MA organization, and the provider of services by close of and the provider of services by close of business of the day after it receives the business of the day after it receives the information necessary to make the decision.information necessary to make the decision.

Valid Notices

Follow the Advance Notice Form Instructions, Follow the Advance Notice Form Instructions, located at located at www.cms.hhs.gov/medicare/bniwww.cms.hhs.gov/medicare/bni

Medicare Advantage Expedited NoticesMedicare Advantage Expedited Notices If an enrollee is not competent, the notice must be If an enrollee is not competent, the notice must be

given to an authorized representative acting on given to an authorized representative acting on behalf of the enrollee.behalf of the enrollee.

If an enrollee refuses to sign the notice, document If an enrollee refuses to sign the notice, document that notice was given but enrollee refused to sign.that notice was given but enrollee refused to sign.

Valid Delivery of Notices

If the MA organization cannot personally deliver a If the MA organization cannot personally deliver a notice to the authorized representative:notice to the authorized representative:

Notify by telephoneNotify by telephoneInform them of the contents of the notice, i.e. Inform them of the contents of the notice, i.e.

effective date, right to file appeal, when and effective date, right to file appeal, when and how to file appeal, date that financial how to file appeal, date that financial liability begins (day after effective date)liability begins (day after effective date)

Valid Delivery of Notices

Cont’d…Cont’d…Provide QIO’s appeal # (1-800-366-Provide QIO’s appeal # (1-800-366-

1486)1486)Inform them to call the QIO no later than Inform them to call the QIO no later than

noon the day prior to the effective datenoon the day prior to the effective dateDocument telephone contact, with Document telephone contact, with

date/time/representative’s namedate/time/representative’s nameF/u by mailing the noticeF/u by mailing the notice

Valid Delivery of Notices

When direct telephone contact cannot be made to When direct telephone contact cannot be made to the authorized representative:the authorized representative:

Send the notice to the representative by Send the notice to the representative by certified mail, return receipt requested.certified mail, return receipt requested.

Date that someone at the address signs (or Date that someone at the address signs (or refuses to sign) is the date of receipt.refuses to sign) is the date of receipt.

Document attempts to contact; include Document attempts to contact; include person initiating call, representative’s name, person initiating call, representative’s name, date and time of attempts, and the telephone date and time of attempts, and the telephone number. number.

Valid Delivery of Notices

When notices are returned by the post When notices are returned by the post office, with no indication of a refusal date, office, with no indication of a refusal date, the enrollee’s liability starts on the second the enrollee’s liability starts on the second working day after the MA organization’s working day after the MA organization’s mailing date.mailing date.

Allow enough time between the Allow enough time between the mailing date and effective date for mailing date and effective date for someone to potentially respond/appeal.someone to potentially respond/appeal.

Detailed Notices Issued by the MA organization, this notice provides the Issued by the MA organization, this notice provides the

enrollee with a detailed explanation of why services are enrollee with a detailed explanation of why services are either no longer reasonable and necessary or are no longer either no longer reasonable and necessary or are no longer covered.covered.

Not given unless the patient calls the QIO for an Not given unless the patient calls the QIO for an appealappeal

QIO will notify MA organization to issue the detailed QIO will notify MA organization to issue the detailed noticenotice

Detailed notice due to QIO no later than close of Detailed notice due to QIO no later than close of business of day of QIO notification about the review business of day of QIO notification about the review request, or the day before the effective date, whichever request, or the day before the effective date, whichever is later.is later.

Reconsideration

If the enrollee disagrees with the QIO’s initial If the enrollee disagrees with the QIO’s initial fast-track appeal determination, he or she may fast-track appeal determination, he or she may request a reconsideration.request a reconsideration.

The enrollee’s (or representative’s) request must The enrollee’s (or representative’s) request must be made no later than 60 days after the initial be made no later than 60 days after the initial appeal determination.appeal determination.

The QIO will use a different physician reviewer The QIO will use a different physician reviewer and complete the review within 14 calendar days and complete the review within 14 calendar days from the date of the reconsideration request.from the date of the reconsideration request.

Administrative Law Judge (ALJ) Review Request

If the enrollee disagrees with the QIO’s If the enrollee disagrees with the QIO’s reconsideration determination, he or she may reconsideration determination, he or she may request an ALJ appeal.request an ALJ appeal.

The enrollee (or representative) must request an The enrollee (or representative) must request an ALJ appeal within 60 days from the date of the ALJ appeal within 60 days from the date of the QIO’s reconsideration determination.QIO’s reconsideration determination.

The QIO must prepare and forward the case to the The QIO must prepare and forward the case to the ALJ within 30 days of receipt of the appeal ALJ within 30 days of receipt of the appeal request.request.

Responsibilities

MA OrganizationMA OrganizationDetermines discharge date and Determines discharge date and

provides detailed notice, upon provides detailed notice, upon request (unless delegated to their request (unless delegated to their contracting providers)contracting providers)

Responsibilities

ProviderProviderDelivers the advance notice, Delivers the advance notice,

Notice of Medicare Non-Coverage Notice of Medicare Non-Coverage (NOMNC), to all enrollees no later (NOMNC), to all enrollees no later than 2 days before their covered than 2 days before their covered services end (effective date)services end (effective date)

Responsibilities

Patient/MA enrollee (or authorized Patient/MA enrollee (or authorized representative)representative)

Acknowledges receipt of the Acknowledges receipt of the NOMNC and contacts the QIO NOMNC and contacts the QIO (within specified timelines) if they (within specified timelines) if they wish to obtain an expedited reviewwish to obtain an expedited review

Responsibilities

QIOQIOImmediately contacts the MA Immediately contacts the MA

organization and the provider if organization and the provider if enrollee requests an expedited reviewenrollee requests an expedited review

Makes decision on the case by no later Makes decision on the case by no later than the day Medicare coverage is than the day Medicare coverage is predicted to end (generally within 48 predicted to end (generally within 48 hours of enrollee’s review request)hours of enrollee’s review request)

Grijalva Regulations

Provide an appeal process for MA Provide an appeal process for MA termination of services decisions.termination of services decisions.

When possible, limit the financial When possible, limit the financial liability to the MA enrollee while the liability to the MA enrollee while the appeal is being considered.appeal is being considered.

MA Appeals Number

AQAF’s Appeals #:AQAF’s Appeals #: 1-800-366-14861-800-366-1486

Insert this number on the Insert this number on the noticenotice

AQAF Contacts1-800-760-4550

Pam Taylor, Beneficiary Protection Program Pam Taylor, Beneficiary Protection Program Manager, ext. 3512Manager, ext. 3512

Barbara Baites, Review Coordinator, ext. 3228Barbara Baites, Review Coordinator, ext. 3228 Anita Meyers, Review Coordinator, ext. 3217Anita Meyers, Review Coordinator, ext. 3217 Laura Rutledge, Review Coordinator, ext. 3429Laura Rutledge, Review Coordinator, ext. 3429 Cathy Dixon, Review Coordinator, ext. 3426Cathy Dixon, Review Coordinator, ext. 3426

Questions????

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. 8SOW-AL-GEN-05-23