CMS Offers Settlement to Acute Care Hospitals and CAHs to Resolve Appeals of Patient Status Denials

To more quickly reduce the volume of patient status claim denials pending in the appeals process, CMS is offering an administrative agreement to any acute care hospital or critical access hospital (CAH) willing to resolve their pending appeals (or waive their right to request an appeal) in exchange for timely partial payment (68% of the net payable amount). CMS encourages hospitals with patient status claim denials currently in the appeals process to make use of this administrative agreement to alleviate the burden of current appeals on both the hospital and Medicare system.

More details about the providers and claims eligible for an administrative agreement, as well as the documents needed to request such an agreement, can be found on the CMS Inpatient Hospital Reviewsweb page.

Details:

• Attend the MLN Connects Call. Registration opening soon at MLN Connects™ Upcoming Calls.
• The administrative agreement covers admissions prior to October 1, 2013
• Administrative agreement requests are due to CMS by October 31, 2014 

Email any questions to MedicareSettlementFAQs@cms.hhs.gov. These questions will be answered on the MLN Connects Call and will be used to create frequently asked questions and answers that will be posted to the Inpatient Hospital Reviews web page. Watch future editions of the eNews for additional updates on this topic.

Center for Medicare Advocacy Sues to Fix Broken Medicare Appeals System

August 26, 2014 – The Center for Medicare Advocacy filed a nationwide class action lawsuit in United States District Court in Connecticut today (Lessler et al. v. Burwell, 3:14-CV-1230, D. Conn.). The five named plaintiffs, from Connecticut, New York and Ohio, have all waited longer than the statutory 90-day limit for a decision on their Medicare appeals. The current average wait time is over five times the congressionally mandated time limit.  The complaint is available here. 

The Medicare Act requires Administrative Law Judges (ALJs) to issue decisions within 90 days after a request for a hearing. Yet, as of July 2014, the current wait time for a decision averaged 489 days. Due to an unjust and time-consuming Medicare appeals process that essentially “rubber stamps” denials at the first two levels of appeal, the ALJ hearing is the third level of appeal, and represents the first chance for a meaningful review of a beneficiary’s appeal – which can include the chance to provide oral and witness testimony.  

“This lawsuit is necessary because of a broken Medicare appeals system. We’re suing to fix it for the Plaintiffs and the thousands of beneficiaries in similar circumstances who are struggling to pay health care bills, or going without needed care while stuck in bureaucratic limbo,” said Gill Deford, Director of Litigation for the Center for Medicare Advocacy.

ALJ wait times have dramatically increased since 2009 in part because of increasing rates of denial at the lower levels of appeal.  

“As a result of the extremely high denial rates at the Redetermination and Reconsideration levels, many beneficiaries must take their claims to the ALJ level, said Judith Stein, Executive Director of the Center for Medicare Advocacy. “Those that ‘wait it out’ for fair reviews with an ALJ are desperately in need of care; they can’t wait an additional two years or more for a decision on their appeal. This system needs to be fixed.” 

Secretary Sylvia Burwell should ensure that the Medicare appeals system provides legitimate reviews at the earliest levels – and timely, fair hearings and decisions for beneficiaries who must seek Administrative Law Judge hearings.

To speak with a representative of the Center for Medicare Advocacy about this case, please contact Lauren Weybrew atlweybrew@douglasgould.com or 646-214-0514.

S&C Letter: Discharge assessment when transferring from certified to non-certified bed

Following is the link to a new Centers for Medicare and Medicaid Services (CMS) Survey and Certification Letter:  Completion of Minimum Data Set (MDS) 3.0 Discharge Assessments for Resident Transfers from a Medicare- and/or Medicaid-Certified Bed to a Non-Certified Beds (8/25/14):

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-43.pdf

·         CMS is reinforcing the requirement and importance of completing MDS 3.0 Discharge assessments when a resident is transferred from a SNF/NF Medicare-and/or Medicaid-certified bed to a non-certified bed.

·         §483.12(a) defines transfer and discharge as “movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility.”

·         §483.20(f) includes the requirement for facilities to “electronically transmit encoded, accurate, and complete MDS data to the CMS System, including … a subset of items upon a resident’s transfer, reentry, discharge, and death.”

·         CMS recognizes that both certified and non-certified beds exist within the same physical structure or certified facility. Discharge assessments are required for residents transferred to non-certified beds housed under the same certified facility.

·         All Omnibus Budget Reconciliation Act (OBRA)-mandated assessments, including discharge assessments, are required assessments that SNFs/NFs must submit to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system.  

·         The RAI User’s Manual Version 1.12 is scheduled to be posted to CMS’ Nursing Home Quality Initiatives website:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html on or about September 5, 2014.