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August 2005

The NEW Expedited Review Process

Many of us have already seen questions as a result of the new regulation regarding Expedited Review Notices. Adding to the confusion are remaining questions about a new Home Health Advanced Beneficiary Notice (HHABN).

The background on these regulations starts with the Benefits, Improvements & Protection Act of 2000 (BIPA). There were also beneficiary advocate groups that filed lawsuits against the Centers for Medicare and Medicaid Services (CMS), resulting in expanding Medicare termination notices. The intent of these new regulations is to ensure due process for the Medicare beneficiaries and provide documentation to them regarding their rights in the appeal process when a termination of Medicare-covered services is pending.

These regulations apply to patients receiving Medicare services in comprehensive outpatient rehabilitation facilities, home care and hospice settings and skilled nursing facility residents.

The Notice of Medicare Provider non-coverage (Generic Notice) must be presented to all patients who are about to be discharged. This applies only when ALL Medicare services are ending. This notice must be delivered at least two days before discharge and in person, unless the discharge is unexpected. In these situations, notices can be mailed after a phone conversation with the staff of the home care agency and the patient. The patient and/or a representative must sign all notices, with a copy placed in the patient’s medical record another copy given to the patient. By signing the generic notice, this ensures the beneficiary has indeed received the notice, and financial liability may be transferred to the beneficiary any days beyond the effective day on the notice that Medicare coverage has ended.

The second notice is the Detailed Notice. If a beneficiary decides to exercise his or her appeal rights, the beneficiary will need to contact the Quality Improvement Organization (QIO) in his or her region. The process will then be: 1) the patient requests an expedited determination no later than noon the day before the effective date that Medicare coverage ends; 2) the QIO will then notify the agency of the patients request for a review; 3) the agency will need to send the Detailed Notice to the beneficiary and the appropriate QIO by close of business on the day of the QIO’s notification that the beneficiary requested an expedited determination; and 4) the QIO then needs to make a decision within 72 hours and will determine who will be responsible for payment of services beyond the coverage period.

The following are examples that have been given for situations when expedited appeal notices were required because of the complete termination of coverage:

  • Treatments no longer medically necessary for beneficiary’s illness

Examples of when expedited appeal notices are not required:

  • Some, but not all services have been terminated
  • The beneficiary chooses to discontinue services
  • Patient or agency personnel conditions are unsafe
  • Hospitalization
  • Nursing home placement
  • The beneficiary relocates
  • Non-compliance of the beneficiary
  • Hospice beneficiary chooses to revoke hospice benefit

Exceptions to the delivery rules are:

  1. The two day prior rule does not apply when beneficiaries are on service less than two days or in cases when unanticipated changes to coverage occur; and
  2. Notices may be mailed rather than hand delivered, following telephone notification to beneficiaries, if discontinuation of non-coverage is unanticipated.

It may be helpful for agencies to have a policy discussing these notices.
Click here for a sample policy that you can customize to your agency.

As far as a new HHABN form is concerned, CMS has told providers to continue to use the HHABN form and procedures that have currently been in place since October of 2002.

There may be instances in which a provider will give dual notices. Both an expedited appeal notice and an HHABN are required where all services are determined to no longer be covered by Medicare, but the beneficiary’s physician has ordered continued services.

For more information visit the CMS web site.

Cyndi Rohret RN, CRNI, CHPN
Clinical Consultant, Briggs Corporation

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