Industry Notes:
Senators Criticize Medicare Appeals Changes
Published on Mon Mar 07, 2005
ALJ changes could restrict access to appeals avenue, top lawmakers say. The plan to shift the administrative law judges from the Social Security Administration to the Department of Health and Human Services has serious problems that could prevent you from receiving a fair shake in appealing your denied claims, Sens. Charles Grassley (R-IA) and Max Baucus (D-MT) warn in a letter to the SSA and HHS secretaries.
The transfer will begin in July and be complete by October (see Eli's HCW, Vol. XIV, No. 10, p. 74).
The problems: HHS plans only three field offices plus a headquarters for the whole nation - not enough locations to provide meaningful access to ALJs. That means ALJs will hear most cases via video conferencing, but HHS doesn't seem to be up to providing video conferencing facilities, the Senators worry.
The field offices still lack staff, and some ALJs will be forced to take on management-related tasks that could distract from their appeals-related responsibilities. Some of the new ALJs may be totally untrained, and the "nuts and bolts" issues of running the new offices remain unsettled, the letter charges. CMS has kicked off a disease management demonstration project to evaluate how new services could enhance chronically ill patients' health, according to a recent Medlearn Matters article.
The three-year project in Florida is available to fee-for-service Medicare beneficiaries with advanced-stage illnesses including congestive heart failure, diabetes or coronary heart disease. Disease management organization LifeMasters will enroll up to 30,000 Flor-ida beneficiaries for the demo.
You could run into problems billing for these patients, however. Because the demonstration has an HMO plan number (H5413) for the DM payments to LifeMasters, intermediaries and carriers may mistakenly apply managed care rules to all claims for them. "No referrals for care are needed and all Fee-For-Service claims will be processed under traditional Medicare payment rules," CMS stresses in the article.
Elimination of the 5 percent add-on for rural home health patients is getting national attention. Newspapers including the Columbus Dispatch and the Arkansas Democrat-Gazette ran stories on the payment reduction last week, with the Associated Press picking up some of them.
"It is simply unfair to reimburse these providers any less than what they currently receive," U.S. Rep. Mike Ross (D-AR) told AP. Without home care, many patients will end up in costlier institutional settings, noted Rep. Vic Snyder (D-AR), who is a physician. The Region D DME regional carrier hopes to educate physicians about durable medical equipment, prosthetics and orthotics.
CIGNA HealthCare's Medicare Web site has launched a new feature called "M.D. Corner." Created by Medical Director Dr. Robert Hoover, M.D. Corner aims to provide DMEPOS information relevant to both practicing physicians and the supplier community. The feature is accessible from [...]
