Assisting Clients with Appeals: Responsibilities and Procedures
Elder Benefit Specialists play a crucial role in assisting clients with various appeals, such as Medicare denials, overpayments, and more. By understanding appeal procedures and deadlines, gathering relevant documentation, and ensuring proper communication with the Benefit Specialist Service Agency (BSSA), EBS can effectively support clients through the appeals process.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author.If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
You are allowed to download the files provided on this website for personal or commercial use, subject to the condition that they are used lawfully. All files are the property of their respective owners.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author.
E N D
Presentation Transcript
OBJECTIVES Learn your role as an EBS in assisting clients with appeals Learn the basics of the appeal procedures for each program Be able to issue- spot for potential appeals
There are several types of appeals the EBS program may help with. Examples include: Medicare Parts A, B, C, & D Medical coverage denials LIS/IRMA Late enrollment penalties Coordination of Benefits and Recovery Private insurance/VA coverage/Marketplace Social Security Benefit denials (except disability appeals!) Overpayments (appeals, waivers, repayment plans) Other appealable adverse actions Medicaid/BadgerCare + Denials of benefits Denials of coverage Overpayments Divestment penalties Community spouse income/asset allocation QMB, SLMB, SLMB+ Reduction of benefits MADA denials Foodshare/WHEAP Any adverse action (e.g., reduction, denial, overpayment) .and more! Most adverse actions = appeal rights TYPES OF APPEALS
*only POA-F or durable power of attorney EBS ROLE CASE INTAKE Elder Benefit Specialists assist clients with various appeals Make note of appeal deadline Gather all relevant documentation 30, 45, 60, 90, 120, 180 days from date of notice (sometimes notice will say, sometimes you ll have to do the math) Medicare Medicaid Social Security Etc. Denial letter or notice, overpayment notice etc. Most will include information on appeal rights E.g. medical records, POWER OF ATTORNEY* documents, prior appeal decisions etc. Sometimes, you may need to have the client sign a release with the hospital or facility to get records. Do this asap. BSSA needs enough information to make a decision on the merit of appeal https://www.timeanddate.com/ https://www.timeanddate.com/ Appeal deadlines may be able to be extended with GOOD CAUSE e.g. the person was in the hospital, but different programs are more strict than others
Appeals are a mandatory contact with your BSSA Any potential appeal, e.g. overpayments, denials, etc. Helpful to include appeal deadline in subject line and attached relevant documents Use https://www.timeanddate.com/date/dateadd.html Most important document to attach is the denial notice, MSN, EOB, adverse letter from Social Security, etc. Rockstar EBS Tip #1: Put appeal deadline in subject line EBS ROLE BSSA CONTACT TO: BSSA FROM: EBS SUBJECT: Medicare appeal deadline is 4/19/2020 Dear BSSA: [Description of case.] Rockstar EBS Tip #2: Attach all pages of MSN or any denial notice if you have them Attached is the MSN and first denial after the client tried to appeal on their own. Thank you, 5-star EBS
After review you and your BSSA may decide not to assist. 1. Verbally tell client of decision and send letter (keep a copy) stating that you are not going to assist the client; and, 2. Make clear that the client has the right to appeal decision on their own. (We never tell a client they have no case or that the case lacks merit. However, we may say something like it s going to be a hard case to help manage their expectations. EBS ROLE DECLINING ASSISTANCE Side note: Sometimes, clients can be more successful on their own, especially with a sympathetic case that has a weak legal argument
EBS ROLE AGREEING TO ASSIST Different options for representation based upon stage in the case, client preference, etc. Have the client sign a client services agreement* FORMS! FORMS! FORMS! BSSA ghostwrite an appeal letter for the client BSSA ghostwrite an appeal letter coming from EBS BSSA write an appeal letter Request a hearing (most hearings are over the phone) Client may attend hearing in the EBS s office CMS forms, OMHA (Office of Medicare Hearings and Appeals) forms, State Fair Hearing Forms, SSA forms etc. (*see sample forms in binder) Now available in Spanish! Note: if your BSSA decides to represent the client, they may have the client sign a limited scope representation agreement. This is different than your EBS client services agreement. Your BSSA will send this for you to have the client sign if need be.
MEDICARE APPEALS PARTS A & B Two types of Medicare coverage appeals Expedited (only Part A) care is ending (hospital, Skilled Nursing Facility (SNF), etc.) Standard (part A or B) service already received but was denied Note: the processes for Medicare Advantage Plans (Part C) are similar but slightly different. We will cover them in the next section.
Slightly different process for hospital or non-hospital (e.g. SNF) Beneficiary will receive a notice: Important Message From Medicare* (hospital) or Notice of Medicare Non- coverage* (non-hospital/SNF) Notice will contain information about appeal rights Beneficiary files appeal with Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) usually over the phone in WI: Livanta (1st level of appeal) Must make decision within one day of receiving all information (hospital) or no later than two days before care is set to end (non-hospital If denied, 2nd level of appeal Request for Reconsideration to Qualified Independent Contractor (QIC) MEDICARE APPEALS PART A- EXPEDITED APPEALS
3rd level of appeal ALJ hearing (use form OMHA-100* to request) Deadline to request hearing: 60 days ALJ makes decision within 90 days 4th level of appeal Appeal to Medicare Appeals Council (MAC) review Deadline to request review: 60 days Council makes decision within 90 days MEDICARE APPEALS PART A EXPEDITED APPEALS 5th level of appeal Judicial review at Federal District Court
Standard appeal already received the care Denied services listed on Medicare Summary Notice (MSN)* Beneficiary receives MSNs quarterly Separate MSNs for part A and part B Not a bill but more like an explanation of benefits Services billed What Medicare paid provider What beneficiary may owe to provider Billing codes and modifiers Denial rationale (hopefully) and sometimes cite to LCD/NCD (Local/National coverage determinations) LCD/NCD database: https://www.cms.gov/medicare- coverage-database/overview-and-quick-search.aspx MEDICARE APPEALS PARTS A & B - STANDARD APPEALS
MEDICARE APPEALS PARTS A & B STANDARD APPEALS Contact BSSA Gather medical records, provider bills, MSN etc. Look for an ABN (Advanced Beneficiary Notice)* - a notice a provider should give before receiving a service if, based on Medicare coverage rules, the provider has reason to believe Medicare will not pay for the service. Original Medicare only. ABN not required for statutorily excluded services
MEDICARE APPEALS PARTS A & B - STANDARD APPEALS Appeal deadline 120 days from date MSN* sent (will be listed on last page of MSN) 1st level of appeal redetermination to Medicare Administrative Contractor (MAC) 2nd level reconsideration to the QIC (deadline 180 days from the decision by the MAC) 3rd level ALJ hearing Use form OMHA-100* to request Standard appeals may take a long time to have an ALJ hearing scheduled 4th level - MAC 5th level - Federal court BSSA will work with you throughout process CMS information on Original Medicare appeals: https://www.cms.gov/index.php/Medicare/Appeals- and-Grievances/OrgMedFFSAppeals/index
MEDICARE APPEALS PART C Medicare Part C aka Medicare Replacement Medicare Advantage Plans Medicare Advantage plans limit services through prior authorization, network restrictions, and other cost containment methods, so the Medicare Advantage plan often denies coverage before patient receives services. Standard appeals Expedited appeals Before service Before service Beneficiary will not receive an MSN After service Care is ending
MEDICARE APPEALS PART C STANDARD APPEALS Before a beneficiary can appeal, plan must issue an organization determination Pre-service determination (like a prior authorization) Post-service determination will receive a denial after receiving the service Notice of Denial of Medical Coverage, EOB, or insert with EOB mailing Similar appeals process, just different timelines to get decisions CMS information on Medicare Managed Care appeals: https://www.cms.gov/index.php/Medicare/Appeals-and- Grievances/MMCAG/index
MEDICARE APPEALS PART C STANDARD APPEALS 1 Two outcomes Plan reviews appeal and reconsiders whether it will cover the service or item Should issue decision within 30 days (60 for post- service appeals) Favorable decision: Plan should cover service or item Unfavorable decision: Plan auto- forwards appeal to the second level (IRE) 1st level of appeal plan reconsideration
MEDICARE APPEALS PART C STANDARD APPEALS 2 2nd level of appeal - Independent Review Entity (IRE) Reviews plan s decision and reconsiders whether it will cover the service or item Should issue decision within 30 days (60 days for post- service appeals) Two outcomes Favorable decision: Plan should cover service or item Unfavorable decision: Beneficiary can choose to move to the next level of appeal
MEDICARE APPEALS PART C STANDARD APPEALS 3 3rd level of appeal ALJ Hearing. Steps: ALJ receives request and sets time and place for hearing Beneficiary receives Notice of Hearing 20 days before hearing ALJ notifies beneficiary of decision by mail Should issue decision within 90 days of hearing request Beneficiary requests Administrative Law Judge (ALJ) hearing within 60 days of receiving the unfavorable reconsideration notice - OMHA-100* form
4 4th level of appeal Medicare Appeals Council Beneficiary requests MAC Review within 60 days of receiving unfavorable ALJ decision MEDICARE APPEALS PART C STANDARD APPEALS MAC reviews ALJ s decision No new hearing. Only reviews evidence from ALJ hearing. Can issue favorable, unfavorable, or remand decision 5 5th (final) level of appeal Federal Court No timeline for decision
Before service beneficiary requests prior approval for a service (similar to standard appeal), but if denied, doctor requests expedited appeal because beneficiary s health would be at risk Appeal steps are the same as a standard appeal, just the timeframe is different Doctor requests expedited prior approval plan has 72 hours to issue organization determination MEDICARE APPEALS PART C EXPEDITED APPEALS If denied, doctor requests expedited appeal plan has 72 hours to issue decision (level 1) If denied, IRE has 72 hours to issue decision (level 2) Levels 3, 4, & 5 - Same steps (ALJ, MAC, Federal Court) and appeal deadlines as standard appeal
MEDICARE APPEALS PART C EXPEDITED APPEALS Care is ending hospital, SNF, home health, hospice or other care is ending Note: we see A LOT of SNF appeals with Medicare Advantage Plans Same process as expedited original Medicare appeal Important Message From Medicare* (hospital) or Notice of Medicare Non-coverage* (non- hospital) Appeal to BFCC-QIO Appeal to (QIC) ALJ hearing MAC appeal Federal Court review
MEDICARE APPEALS TIPS Look up the coverage criteria Build your case Get the facts/story Collect relevant documents Doctor s letters Medical records MSNs ABNs NOMNC Provider billing statements EVIDENCE OF COVERAGE (advantage plans) Coverage criteria for advantage plans (Part C is the same as Medicare because they must cover at least what Medicare covers, but may cover more. Must obtain EVIDENCE OF COVERAGE, which is the plan s document stating if/what they cover above and beyond what Medicare covers. https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx LCD/NCD database: https://www.cms.gov/medicare-coverage- database/overview-and-quick-search.aspx Medicare Benefit Policy Manual: https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Internet- Only-Manuals-IOMs-Items/CMS012673 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673 https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673
MEDICARE APPEALS PART D Part B and Part D both cover outpatient prescription drugs Part B drugs: administered by doctor Part D: self-administered Part B and Part D drug denials do not use same appeal process Part B drug denials - Appeal using Original Medicare or Medicare Advantage appeal process Note: LIS/Extra Help and Late Enrollment penalty appeals go through the Social Security Administration (SSA) Part D drug denials - Appeal using Part D appeal process Possible coverage problems > Part B drug billed to Part D
Two situations: 1. Beneficiary goes to pharmacy and learns plan will not cover prescription Possible reasons for non-coverage Refill requested too soon Drug is not on plan s formulary Drug is subject to utilization management tools Prior authorization, step therapy, quantity limits Drug is excluded from coverage for any Part D plan E.g., over-the-counter drugs, medications for weight loss and gain, drugs that treat cold symptoms etc. 2. Beneficiary goes to pharmacy and finds drug is too expensive Higher tier MEDICARE APPEALS PART D
Next steps (before filing an appeal) 1. Beneficiary contacts plan to find out reason it will not cover drug 2. Beneficiary files formal coverage request or an exception request to Part D plan: MEDICARE APPEALS PART D Standard: Should issue decision within 72 hours Expedited: Should issue decision within 24 hours 3. Beneficiary receives coverage determination. If unfavorable decision, beneficiary can begin appeal.
CMS information about exception requests: https://www.cms.gov/Medicare/Appeals-and- Grievances/MedPrescriptDrugApplGriev/Exceptio ns A tiering exception - requested to obtain a non- preferred drug at the lower cost-sharing terms of a low tier. A formulary exception - requested to obtain a Part D drug that is not included on a plan s formulary, or to request to have a utilization management requirement waived (e.g., step therapy, prior authorization, quantity limit) for a formulary drug. CMS information about coverage determinations: https://www.cms.gov/Medicare/Appeals-and- Grievances/MedPrescriptDrugApplGriev/CoverageDet erminations- MEDICARE APPEALS PART D
Next step - beneficiary files an appeal. MEDICARE APPEALS PART D Appeal process is similar to other parts of Medicare: Plan redetermination > IRE reconsideration > ALJ Hearing > MAC appeal > Federal court
Late Enrolment Penalty (LEP) Other types of appeals are related to Medicare but follow a different process Income-Related Monthly Adjustment Amount (IRMAA) MEDICARE APPEALS LEP, IRMAA, COB&R ETC. Some appeals related to Medicare go through the Social Security Administration (SSA) Medicare start date/entitlement/termination SSA - Program Operations Manual System (POMS) HI https://secure.ssa.gov/apps10/poms.nsf/chapterlist!openviewrestricttocategory=06 section (health insurance) https://secure.ssa.gov/apps10/ poms.nsf/chapterlist!openvie w&restricttocategory=06 Medicare Overpayments https://secure.ssa.gov/apps10/poms.nsf/chapterlist!openviewrestricttocategory=06 https://secure.ssa.gov/apps10/poms.nsf/chapterlist!openviewrestricttocategory=06
SOCIAL SECURITY APPEALS EBS assist with all types of Social Security appeals except disability appeals Examples of SSA appeals: Disability appeals may be handled by private attorneys since these are fee-generating cases We might consider taking the case if the client has tried contacting private attorneys who refuse to take the case, but this is rare Overpayments (for a variety of reasons) Next overpayments webinar will be on April 6! Waiver denials Incorrect benefit amounts SSI appeals (over resources, over income etc.)
Reconsideration (form is SSA-561*) Hearing by an administrative law judge (ALJ) Form HA- 501* SOCIAL SECURITY APPEALS Review by the Appeals Council Federal Court review
SOCIAL SECURITY APPEALS SSA-1696* (Appointment of Representative Form) If representing client, you or your BSSA will sign on as auth rep. Never sign 1969 without BSSA approval Note: For most other appeals, including Medicare, a Power of Attorney for finances or durable power of attorney may sign the appeal in place of the beneficiary (need to attach POA documents to appeal). SSA does not recognize Power of Attorney to appoint representative or appeal. That person would need to go to SSA to request to become the representative payee. OR if the beneficiary is not incapacitated, that person can sign the appeal and the appointment of rep form.
Reconsideration (appeal) 60-day deadline can be extended with good cause If the SSA decision is wrong, not enough info., numbers don t add up etc. Waiver Can be requested at any time Form is SSA-632 The overpayment was not the person s fault and they cannot afford to pay it back (or it s unfair for some other reason) SOCIAL SECURITY APPEALS - OVERPAYMENTS Repayment Plan Can request reduced repayment amount at any time Form is SSA-634 Use when the overpayment is correct and is the person s fault If the person gets LIS/Extra help, they can request $10/mo. repayment amount
Medicaid Denials of benefits/coverage Prior authorization denial Coverage denial Overpayments If someone should not have been eligible they will have to pay back benefits MEDICAID APPEALS Divestment penalties Community spouse income/asset allocation QMB, SLMB, SLMB+ Reduction of benefits MADA denials Denial of disability (similar but different than SSA disability)
MEDICAID APPEALS Denial of coverage of an item or service either before (prior authorization) or after Coverage criteria Forward Health Portal https://www.forwardhealth.wi.gov/WIPortal/ Click Online Handbooks Click BadgerCare Plus and Medicaid
MEDICAID APPEALS Generally 45-day appeal deadline from the date of the adverse action Form* used to request hearing in front of ALJ (DHA) Hearing is over the phone BSSA will usually write a brief & submit exhibits, usually due 2 days before hearing Rules are http://www.emhandbooks.wisconsin.gov/meh-ebd/meh.htm (MEH) or http://www.emhandbooks.wisconsin.gov/bcplus/bcplus.htm BC+EH
FOODSHARE & ENERGY ASSISTANCE APPEALS USE THE SAME FORM AS MEDICAID APPEALS & SAME PROCESS FOODSHARE ELIGIBILITY HANDBOOK: ENERGY ASSISTANCE (WHEAP) MANUAL: http://www.emhandbooks.wisconsin.gov/fsh/fsh.htm HTTP://WWW.EMHANDBOOKS. WISCONSIN.GOV/FSH/FSH.HTM http://homeenergyplus.wi.gov/docview.asp?docid=28805locid=25 HTTP://HOMEENERGYPLUS.WI.G OV/DOCVIEW.ASP?DOCID=28805 &LOCID=25 http://www.emhandbooks.wisconsin.gov/fsh/fsh.htm http://homeenergyplus.wi.gov/docview.asp?docid=28805locid=25 http://homeenergyplus.wi.gov/docview.asp?docid=28805locid=25
FINAL THOUGHTS Any potential appeal is a mandatory contact with your BSSA when in doubt, reach out Almost all adverse actions come with appeal rights. Those rights are usually stated on the same notice or letter. Some appeals can be faxed, some can be emailed, some can be phoned in, and some can only be mailed. Details about the process are usually on the same notice or letter. Most appeals need to be signed by the client or the client s POA (for finances or durable power of attorney or guardian except Social Security does not recognize POA. That person would need to request rep payee status. PUBLIC BENEFIT APPEALS AT A GLANCE in your binder. Use as a quick reference guide.
THE END Questions?
