Rehab:
CORFs Given New M+CO Appeals Responsibilities
Published on Wed Feb 18, 2004
5 tips for mastering notification requirements.
New fast-track appeals requirements are catching most comprehensive outpatient rehab facilities by surprise, and it's a nasty surprise indeed.
As required by a settlement in the Grijalva v. Shalala lawsuit, the Centers for Medicare & Medicaid Services began requiring new notices of termination of coverage for Medicare+Choice enrollees Jan. 1 to facilitate speedy appeals decisions. And the requirements for the fast-track appeals process are translating into extra costs and headaches for CORFs that contract with the Medicare managed care plans.
In addition to the termination of coverage notice, CORFs (along with skilled nursing facilities and home health agencies) also must furnish documentation supporting the termination decision to the independent review entity (IRE) - generally a quality improvement organization (QIO) - in time for the decision deadline of four days from the initial notice.
"It seems like an anomaly to include CORFs with SNFs and HHAs in these requirements" notes Cherilyn G. Murer, president and CEO of Murer Consultants Inc. in Joliet, IL. That's because CORFs' coverage windows are based on medical necessity, not on structured timetables like SNFs and HHAs, she explains.
Nonetheless, CORFs are included and must comply with the new rules.
Get ahead of the pack: The Grijalva requirements have caught many CORFs unaware, says Burtonsville, MD-based attorney Elizabeth Hogue. And unfortunately, many "are going to get bitten first, before they wise up," she says.
This bite will come from the Medicare+Choice organization itself - and it's likely to be biting in anger. That's because if CORFs fail to deliver the notice at least two days before discharge, the M+CO is on the hook for coverage of the services until the notice is delivered and the fast-track appeals process timeline starts.
What to expect: To keep CORFs in line with the requirement, CMS has given M+COs freedom to penalize providers however they see fit. That will likely translate into things like withheld payments and terminated relationships - "scary stuff," according to Hogue. "They're shifting the burden of compliance to providers," she says.
In fact, CMS repeatedly has told plans and providers that it won't referee between them on the details of the notice-delivery system. Plans and providers must work out those details themselves in their contracting agreements. Ramifications for noncompliance "will be a work in progress," predicts Murer.
"Accomplishing proper advance notice of termination by the provider is going to require coordination and information-sharing between those entities to make sure that enrollees get the right information at the right time," a CMS staffer stressed in a recent open door forum on the matter.
Opening up those lines of communication could be one very positive result of these requirements, opines Ken Mailly with Mailly & Inglett Consulting in Wayne, NJ. But "a lot more than communication" between plans [...]
