Jurisdictions A and B: Phone demo is coming your way

WASHINGTON - Christmas has come early for HME providers who have disputed Medicare claims.

CMS announced last week that it plans to expand a demonstration project—one that allows providers to speak with reconsideration professionals by phone to try to resolve their denied claims; or re-open denied claims that are stuck at the administrative law judge level—to jurisdictions A and B on Nov. 1.

“We've been waiting for this with bated breath,” said Andrea Stark, a reimbursement consultant with MiraVista. “We knew it has been a successful demo, but this expansion underscores that success and the volume of claims it has been able to remove from the backlog at the ALJ.”

The demo, which launched in 2016, was able to re-open and remove some 81,000 appeals from the backlog in 2017 and is poised to re-open and remove more than 100,000 in 2018.

C2C Innovative Solutions, which runs the demo as the Qualified Independent Contractor for HME, says it will be ready to flip the switch in jurisdictions A and B on Nov. 1. It helps that the contractor has established relationships with the two DME MACs that cover all four jurisdictions.

“We already have good communications with Noridian Healthcare Solutions and CGS Administrators for jurisdictions C and D, and we already deal with a larger quantity of claims in those jurisdictions,” said Emily Barnes, education and outreach specialist for the demo at C2C Innovative Solutions. “We're adequately staffed; we're ready to go.”

One thing C2C Innovative Solutions is ramping up: its education efforts. The contractor is reaching out to state associations in jurisdictions A and B to get them to help get the word out about the demo.

“It does take some education,” Barnes said. “In 2016, we were seeing only 30% of our letters asking for re-openings returned. That's gone up to 65%.”

Unlike in jurisdictions C and D, where the demo initially applied only to claims for oxygen and diabetes supplies, it will apply to all claims in jurisdictions A and B, except for diabetes supplies (and claims involved in other initiatives, like prior authorization for power mobility devices).

“I think CMS thinks that the denial rate is so high for diabetes supplies that it needs another initiative to really address it,” Barnes said. “So we do understand why.”

Going forward, Stark says she'd like to see other contractors given the same “latitude” that C2C Innovative Solutions has been given to re-examine denied claims.

“It would be nice if that discretion they've been given would extend to the lower level of appeal, so it doesn't even have to get to that level to begin with,” she said. “That would really make the process go faster.”

While C2C Innovative Solutions is still waiting to hear about the fate of the QIC contract for HME—it successfully appealed CMS's decision to award the contract to Maximus—CMS's expansion of the demo should bode well for the contractor.

“We thought CMS would have taken care of that before expanding the demo, but we're happy they've expanded the demo and we're hoping for the best,” Barnes said.