Medicare
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- Access to Prosthetics and Orthotics Through Medicare
- Recent Medicare DME Changes
- The Appeal Procedure for Medicare Part B Claims
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Access to Prosthetics and Orthotics Through Medicare
Funding requests for orthotics or prosthetics will always need a physician's prescription. A substantial majority of vendors will accept "assignment" for these devices. The orthotics coverage, insofar as braces are concerned, is limited to leg, arm, back and neck braces. Orthopedic shoes are excluded from coverage. There is no similar limitation concerning prostheses.
Medicare uses what is known as an "L-Code" system in conjunction with Level II or "K-Modifiers" for billing these devices. Essentially, these "K-Modifiers" (K0 to K4) measure the patient's rehabilitation potential as determined by the prosthetist and physician. Those with a higher K level, such as K4, have better ambulation ability or potential and will be able to access a greater range of prosthetic components.
Medicare DME Changes
- Beginning in October 2001, Medicare instituted an Advanced Determination of Medicare Coverage (ADMC) for customized wheelchairs. The ADMC is basically a prior authorization, which gives vendors advance notice as to whether Medicare will cover the cost of these devices. Medicare may expand the ADMC process in the future to other types of DME.
- Medicare has a policy regarding the Advance Beneficiary Notice (ABN). The ABN is a written notice that a health care providers or DME suppliers must give to a beneficiary before providing any service or item that they think Medicare will not pay for. The ABN lists the services and items not covered and the reason why Medicare will not pay. The beneficiary then has the option to pursue purchase of the non-covered item/service with personal funds or other insurance. By signing the ABN, the consumer commits to payment for the non-covered items.
- Medicare now covers treatment for persons with Alzheimer's disease.
The Appeal Procedure for Medicare Part B Claims
Original Medicare Plan
A Medicare beneficiary or service provider who does not agree with a Medicare carrier's decision has a right to appeal that decision. If Medicare denies an equipment claim or fails to reimburse the correct dollar amount, the equipment supplier who accepted assignment will usually attempt an appeal. If not, the beneficiary may wish to do so with assistance from DATI, other agencies, and/or the prescribing physician. Regardless of who takes the lead, the procedure is pretty much the same.
Request for Review of Initial Determination
Under Part B Medicare, either the beneficiary or the supplier must file a request for review in writing within six months of the time the initial decision was made. This is a paper review. Information about where to send the request, the deadline date for appeal, and the reason for denial all appear on the consumer's Explanation of Medicare Benefits (EOMB) form. The Medicare Summary Notice, or MSN, is replacing the EOMB notice. However, some Medicare carriers have not yet phased in this change.
Valid claims may be denied for several reasons, and the reason appearing on the EOMB/MSN will not always provide a clear explanation. Statements frequently used include "not medically necessary" or "not prescribed by a physician." A denial under medical necessity could mean any one of several things. It could mean that one of the criteria check-offs on the CMN was left blank, or that a HCPCS code was missing or incorrect. It could also mean that more information about the patient's condition is needed. The "not prescribed" reason can appear if the doctor fails to date his/her signature or omits the UPIN number. It is usually helpful to get an additional letter of support from the prescribing physician if a claim is denied as "not medically necessary." Ideally, this letter would contain additional evidence of the patient's medical/functional need for the prescribed equipment. Also, equipment dealers are usually very good at detecting what is missing from the CMN and will often assist the doctor with addressing specific points of Medicare coverage criteria. Consumers, their physicians, and DME suppliers are also welcome to contact the DATI for assistance. Appeals are usually very successful. Many denials are reversed on appeal.
Request for Fair Hearing (Carrier Hearing)
If the review decision is unsatisfactory and the disputed amount is $100 or more, the consumer (Disputed claims can be combined to add up to the required amount for the appropriate appeal level (Fair Hearing, ALJ, or Federal Court) or service provider may submit a Request for Fair Hearing. This is also known as a Carrier Hearing. Again, the request must be in writing, and must be postmarked within six months of the review decision. Equipment denials that reach this level are often disputes about the medical necessity of the prescribed device(s). A supplementary letter of support from the prescribing physician is essential at this stage. Again, doctors are encouraged to tap the equipment suppliers or the DATI for hints about how to make their additional documentation speak directly to the denial issues and Medicare coverage criteria. Even the most compelling argument will be ineffective if it does not address the specific reason for denial.
Request for Administrative Law Judge (ALJ) Hearing
If the fair hearing does not yield satisfactory results, and the amount in dispute is $500 or more ($100 or more for denials of home health benefits), the consumer or service provider may file a request for a hearing before an ALJ. This request must be filed within 60 days of the fair hearing review. The beneficiary can testify, bring witnesses and additional evidence, and present arguments to support his/her claim.
Departmental Appeals Board Review
A beneficiary who receives an unfavorable decision from the ALJ has 60 days to request a review by the Departmental Appeals Board. As at the ALJ hearing, the beneficiary may submit additional evidence and make additional legal arguments. The Appeals Board's function is to consider whether the ALJ misinterpreted the law or facts.
Federal Court
Those cases that are not resolved at earlier levels may be appealed to Federal Court if the disputed amount is $1,000 or more. Consumers who wish to appeal to Federal Court may consider contacting the Community Legal Aid Society, Inc (CLASI) office in their county for possible assistance.
Medicare Appeals: Part B Coverage Determinations
The following table summarizes the Medicare appeal process, time limits, and procedures.
Step |
Time Limits |
Reviewing Agency |
Procedures & Rights |
Notes |
|---|---|---|---|---|
Initial Determination |
If request not acted upon within 60 days
after carrier receives it, delay constitutes an appealable
denial |
Carrier issues Medicare Summary Notice
(MSN) |
Beneficiary has right to appeal if: carrier pays less than expected, carrier denies coverage, new information is available to support claim, error in processing original claim. Provider may also file an appeal. |
The appeal process can continue from
the review stage up through later stages to federal court
when the amount in controversy meets certain requirements |
Request for Review of Initial Determination |
Must file CMS Form 1984 within 6 months
of initial determination |
Carrier employee other than person who
made initial determination |
Beneficiary may submit additional evidence. Paper
review only. |
Review decisions often contain a more
complete explanation of reasons for denial |
Fair Hearing (Carrier Hearing) |
Must request within 6 months of receiving
review decisions |
Hearing officer paid by carrier conducts
hearing |
Amount in controversy must be at least
$100. Hearing procedure is informal. Hearing officer has
no subpoena power. Hearing officer must follow CMS manual
guidelines. |
Beneficiary may aggregate claims to meet
the $100 jurisdictional requirement. Carriers must complete
90% of Part B hearings within 120 days of request. Carriers
must also provide hearing if request for payment was not
acted upon with reasonable promptness. |
Administrative Hearing (ALJ) |
N/A |
Social Security Administration ALJ conducts
hearing |
Amount in controversy must be at least
$500 ($100 if the case involves denial of home health benefits) |
Beneficiary may aggregate claims to meet
the $500 jurisdictional requirement for ALJ hearing. |
Departmental Appeals Board Review |
Must request within 60 days of ALJ hearing
decision |
N/A |
Paper review only. Beneficiary may submit
additional evidence and legal arguments. |
|
Judicial Review |
Complaint must be filed within 60 days
of Appeals Board decision |
U.S. Federal District Court |
Amount in controversy must be at least
$1,000. All rights available to litigants in civil cases
in Federal District Court. |
|
Medicare+Choice Appeals
Appeals of carrier determination under Medicare+Choice plans involve a number of steps. Beginning January 1, 2004, beneficiaries under Medicare+Choice plans will have the right to a “fast-track” appeals process involving independent doctors reviewing the case. These are sometimes called Part C Appeals. The early stages of this process are handled internally by the carrier (MCO or private fee-for-service plan) before being sent to an outside contractor, the Center for Health Dispute Resolution (CHDR), which is retained by CMS. The stages include:
Organization Determination
The Organization Determination is the initial decision made by the MCO (carrier) that sponsors the health plan in which a member is enrolled when a complaint about a service or payment decision is filed. The MCO must make its determination within 14 days after the date it receives the member's request. This process is expedited in cases of medical urgency, based upon certain criteria (e.g., doctor requests expedited consideration, or MCO agrees that the standard time frame could seriously jeopardize the life or health of the member or their ability to regain maximum function). In these matters, each stage of the appeal must be resolved within 72 hours.
Request for Reconsideration
If dissatisfied with the Organization Determination, the member can request that a different decision maker at the carrier consider the appeal. This request must be made within 60 days of the Organization Determination. This review is done strictly on the information in the files. The MCO has 30 days to reconsider its determination, or 72 hours in expedited cases.
Independent External Review Organization (by CHDR)
If the decision upon a Request for Reconsideration is unfavorable to the member, the case is automatically sent to an Independent External Review Organization. The Center for Health Dispute Resolution (CHDR) currently is that organization. The file sent to CHDR contains the MCO's written justification for its decision. The member is notified of this development by a letter from the carrier as well as by a letter from CHDR advising the member of the right to submit any additional information relevant to the appeal. If the appeal involves a question of "medical necessity," it is also reviewed by a physician. The CHDR is not under any statutory or regulatory time limit but it tries to make its decisions within 60 days, and within 10 days in expedited cases.
ALJ Hearing
The next step in the appeals process is an ALJ hearing, mirroring the rights and procedures at an ALJ Hearing on the fee-for-service side. This request must be made within 60 days of the ALJ decision. One difference, however, is that the amount in controversy need only be $100, not $500 as in fee-for-service appeals.
Departmental Appeals Board Review
Again, as on the fee-for-service side, the member may request a hearing before the Departmental Appeals Board if dissatisfied with the ALJ's decision. The time limit is again 60 days.
Federal District Court
An appeal of the Departmental Appeals Board decision can be brought to Federal District Court by either the member or the MCO within 60 days if the amount in controversy is at least $1,000.
