Traditionally, the MACs and QICs have had discretion during the appeal process to develop any new issues identified during the review and have been able to assess all aspects of coverage and payment related to the given claim. This has resulted in claims being denied in redeterminations and reconsiderations for new issues outside of the original denial reason being appealed. This has added to the current ALJ (Administrative Law Judge) backlog we have seen in the last two years. Suppliers have been forced to continue up the appeals chain for each newly identified denial reason.
This clarification is effective for redetermination and reconsideration requests received on or after...
Another exception to this guideline speaks to claims denied for insufficient documentation. If a claim is denied in post-payment review for insufficient documentation, and is appealed with never before presented documents, it can be denied for an issue other than the original denial reason.
In order to ensure that appeals contractors are aware of the original post payment denial reason, CMS is encouraging suppliers to include the audit or review results letter with any appeal.
This notice is a great win for suppliers who have struggled with denials throughout the appeal process. We are cautiously optimistic that CMS will eventually entertain the idea of expanding the protocol to pre-payment review decisions as well. We continue to see a concerted effort from CMS to hear the concerns of DME suppliers regarding the laborious appeals process. Ultimately, this clarification should reduce the number of claims forced into higher levels of appeal for new reasons not identified in the initial denial.
Just as CMS is rethinking their approach to the appeals process, it is time to start rethinking the way you manage your denials. Join us on September 23rd for a comprehensive understanding of common denials, tips for researching and resolving recurring denials and special insights from DME Consultant and Billing Specialist Andrea Stark to prevent future denial occurrences. Get the details on our webinars page.