Practice Management Alert

When your Medicare Part B carrier conducts a review of your appealed claim and upholds its original decision, should you take the next step in the Medicare appeals process? If you feel your appeal is justified, have the documentation to support your argument, and meet the Medicare requirements to move to the second, fair hearing step, billers and practice managers say you should absolutely continue. Many practices find that when they receive an unfavorable decision at the review step, appealing to the fair hearing step produces favorable results.
 
The key to winning at the fair hearing is having the documentation to support your claim and your argument. "Having the documentation from the physician is number one," stresses Joshua Klinge, CPC, HRS, chief executive officer of Optimum Reimbursement Services Inc., a medical billing company based in Huntington Beach, Calif., that specializes in appeals for surgeons. "If the documentation is not there to substantiate what you are billing and arguing, the hearing officer will not even consider siding with you."
 
A hearing officer appointed by the Medicare carrier conducts the nonadversarial, fair hearing. Although the hearing officer can be an employee of the carrier, based on a 1982 U.S. Supreme Court ruling, CMS in its Medicare Carriers Manual mandates that the officer must be independent. CMS requires a hearing officer to have a thorough knowledge of the Medicare program, including the laws and regulations that it is based on, and CMS rulings and policies. The hearing officer must not be involved in any way in the initial determination or appeal to the review step with the claim at issue. Officers can be attorneys or individuals who can conduct formal hearings and have a general understanding of medical issues and terminology.

To qualify for the fair hearing, your claim must have been appealed through the review step and have at least $100 in controversy. (See page 3 to learn how to determine the amount in controversy.) You have six months from the date of the review determination to file a request for the hearing. The request for a hearing must be made in writing, by sending a letter to the Medicare carrier or by completing Form CMS-1965, Request for Hearing, Part B Medicare Claim, which you can obtain from your Medicare carrier. If you choose to request a fair hearing by letter, as most practices do, it should include the following:

 

a statement of dissatisfaction with the review determination
 

a request for a hearing before a hearing officer and the type of hearing desired
 

the name of the patient
 

the health-insurance claim number
 

the carrier's name and address
 

your name, address, phone number and signature
 

why you disagree with the review determination.

Attach a copy of the review-determination notice and any additional evidence and documentation you have to support your argument. Klinge says the documentation may include operative reports, progress notes, reports on history and physical of the patient, medical journal articles, items from specialty medical books, correct coding edit materials and any other medical literature that gives facts and findings that support your argument. "I think it's better to have too much information than not enough. The more supporting documentation, the better."
 
As the appellant, you may select the type of hearing. Your choice should be included in the hearing request. There are three types of hearings:

 

In-person. The parties involved in the claim appear before the hearing officer. The appellant can give oral and written testimony to support the case and can challenge the information used to deny the claim. Witnesses may also give testimony if the hearing officer believes such testimony would help determine the facts in the case.

 

Telephone. The hearing is conducted on the telephone. Parties involved in the hearing give oral testimony and can ask questions. Written evidence can also be submitted by mail or fax.

 

On-the-record (OTR). The hearing officer examines the facts from information in the case file and any additional information obtained by or given to the hearing officer by the parties involved in the case.

The type of hearing you choose depends on your preferences. An in-person hearing can be time-consuming, inconvenient and costly because of travel involved. Although a telephone hearing can remedy those problems, some people may find it difficult to effectively present their case over the telephone. An OTR hearing can be held and decided quickly, based on the written material on file. It may be the choice for those with good written communication skills, Klinge says. He prefers an OTR hearing because it permits him to carefully craft his argument and precisely state his case. If you opt for an OTR hearing, the hearing officer will use the documentation you supply and the supporting information, along with your argument stated in your fair hearing request letter.
 
Klinge had a case in which a Medicare patient with multiple medical problems was in an auto accident and required critical care treatment and surgical services by two general surgeons on the same day. The local carrier denied the critical care codes that were modified as a significant and separately identifiable E/M service by the same physician on the same day of the procedure or other service. The denial was based on local carrier rules that allowed only one E/M service per day per specialty. "This patient had so many problems in the trauma unit that, in this case, the local carrier rules should not apply," Klinge argues.
 
When the payment denial was appealed to the review step, the carrier confirmed its original decision, Klinge says. "So, I wrote a letter requesting an on-the-record hearing. I listed the subject and codes on the letter. I submitted all the operative notes, critical care reports and the history and physical of the patient. I explained in the letter what was done, how the patient's diagnoses were considered and evaluated and that we used the modifier because we believed what was done was above and beyond the surgical procedures performed. Nearly 60 days later, I got a notice that the decision was favorable, that the critical care charges were denied incorrectly, and the initial request for payment on the services was confirmed." About 13 days later, a $655 payment for the services was received.

Klinge says his appeal letter for the hearing won the case because it was specific to the case, simple and to the point. "I write every appeal letter individually and try to be as explanatory as possible. I would hesitate to use medical terminology, he says. "Laymen's terms have always worked for me. That's because 99 percent of the time, the reviewer or hearing officer is not a physician. And, a form letter doesn't do it justice. When you are dealing with the same carrier all the time, it seems that once they start seeing the same form letter, such as one for services modified as unusual procedure services, they'll keep denying it. That's because each individual appeal is supposed to be case-specific, as the letter appealing it should be."
 
Arguing for payment on a claim that was denied by Medicare as not medically necessary was best accomplished in a telephone hearing for Lori Wyvill, office manager for Suzanne Weakley, MD, an allergist in Houston. During the hearing, Wyvill worked for a billing company that handled claims for gynecology and cardiology practices. The practice received a denial that the services were not medically necessary due to multiple diagnoses, she says. "The carrier claimed the diagnoses were duplicates. When I went through the medical records, I could identify at least three different diagnoses for the patient. During the hearing, I was asked why we thought this should be paid, and I went through the record and the chart notes and pointed out the diagnoses. I argued the diagnoses were distinct, and denying them as duplicates was not accurate. Then, I described how what was done met the criteria for medical necessity. All the records were in front of them, and it could not have been any clearer. A couple weeks after the hearing, we got paid."
 
Pursuing the Medicare appeal to the fair hearing stage satisfied Klinge and Wyvill. Klinge says that of the half-dozen appeals he has taken to the fair hearing stage in the last two years, all have produced payment, and none required further appeal. Once, Wyvill says, a telephone hearing convinced her that she was wrong about a claim. Although she lost the appeal, she was satisfied with the result and did not pursue the case further. Despite the one unfavorable hearing outcome, Wyvill encourages practices to proceed through the Medicare appeals process if they believe they have a case.
 
Note: For more information on the appeals process, see "Win Medicare Appeals at Review Step With Well-Crafted Letter" in the December 2001 issue of Medical Office Billing and Collections Alert.