MAXIMUS - Center for Health Dispute

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Medicare + Choice AppealsConference : 

Medicare + Choice AppealsConference MAXIMUS Center for Health Dispute Resolution

Medicare Managed Care Reconsideration Project : 

Medicare Managed Care Reconsideration Project New at MAXIMUS CHDR Working with MAXIMUS CHDR Appeals Data

What’s New : 

What’s New ISO 9001:2000 Certified New Manual New Website

Quality Policy : 

Quality Policy All staff and suppliers to MAXIMUS CHDR understand and meet or exceed, customer requirements so as to provide timely, unbiased, expert medical insurance appeal determinations, thereby assisting our government clients to better serve the people.

ISO 9001:2000What is it? : 

ISO 9001:2000What is it? Internationally recognized quality management system standard Developed by International Organization of Standardization Emphasizes quality standards in: Systems Procedures Documentation

ISO 9001:2000What does certification mean? : 

ISO 9001:2000What does certification mean? MAXIMUS CHDR subject to audit conducted by outside independent auditor. Independent auditor determines whether the procedures, practices and quality systems meets the defined ISO standards. MAXIMUS CHDR passed initial audit with “no findings”. Periodic re-certification.

Impact on Medicare Managed Care Reconsideration Project : 

Impact on Medicare Managed Care Reconsideration Project Decision Processing Appeal Officers Independent Physician Consultants Internal Audit

Decision Processing : 

Decision Processing Documented MAXIMUS CHDR appeal processing Increased Internal Quality Reviews

Appeal Officer : 

Appeal Officer Created specialized teams Team Leaders Over 30 years combined experience Monitor timeliness/quality Quality Reviews Increased sample on monthly basis for each team member Internal Quality Control Monitoring Tool used to capture and measure

Independent Physician Consultant : 

Independent Physician Consultant Structured medical review instrument, with attestation Verified assessment of medical reviewer’s cases by 1st level reviewer Review by Medical Director or peer of questionable medical reviewer determinations

Independent Physician Consultant : 

Independent Physician Consultant Review of new medical reviewer’s cases by Medical Director or peer until production of two error-free reviews in a row Sampling of at least five percent of decisions on an annualized basis Documented real time feedback to reviewers for corrective action (for example, re-education)

Customer Contact : 

Customer Contact Customer defined as CMS, Medicare managed care plans and enrollees MAXIMUS CHDR welcomes comments, suggestions and feedback Continuous cycle of feedback, evaluation, improvement

M+C Reconsideration Process Manual : 

M+C Reconsideration Process Manual Effective January 2003 Includes information on How to contact MAXIMUS CHDR Considerations for development How to submit case file to MAXIMUS CHDR MAXIMUS CHDR Reconsideration Process New data collection efforts New decision letters

Medicare Managed Care Reconsideration Project Web Site : 

Medicare Managed Care Reconsideration Project Web Site

Medicare Managed Care Reconsideration Project Web Site : 

Medicare Managed Care Reconsideration Project Web Site Located at www.medicareappeal.com Pages for enrollees, health plans, researchers Case status search Updated daily (1.5 day lag from case receipt/action) Search by case number or plan contract number Problems with web site? Contact us at medicareappeal@maximus.com

Medicare Managed Care Reconsideration Project Web Site : 

Medicare Managed Care Reconsideration Project Web Site

Working with MAXIMUS CHDR : 

Working with MAXIMUS CHDR Reconsideration Background Data Form Case file submission Submitting additional information Reopening requests Data Reports

Reconsideration Background Data Form : 

Reconsideration Background Data Form Common Issues Case Class Processing Dates Impact on Data Reports to CMS

Reconsideration Background Data FormCommon Issues : 

Reconsideration Background Data FormCommon Issues Enrollee Medicare # Validate Enrollment Incorrect number delays case initiation Plan Contract # Validate MCO Compliance Reporting “Recycled” Forms – Representative Issues

Reconsideration Background Data FormCase Class : 

Reconsideration Background Data FormCase Class MAXIMUS CHDR can change class at its level. Examples: -Claim appeals cannot be expedited -Certain SNF appeals

Reconsideration Background Data FormPlan Processing Dates : 

Reconsideration Background Data FormPlan Processing Dates Section VI(B) – Reconsideration Determination Processing Dates Date of valid appeal request Date of decision by Plan What is a valid appeal?

Reconsideration Background Data FormImpact on Data Reports : 

Reconsideration Background Data FormImpact on Data Reports Representative Documentation Date of valid appeal request means date valid AOR received by plan If no valid AOR received, then no date of appeal request

Reconsideration Background Data FormImpact on Data Reports : 

Reconsideration Background Data FormImpact on Data Reports Plan Contract Identification Use contract number of enrollee’s plan Plan Processing Timeliness -MAXIMUS CHDR reports plan timeliness using reconsideration dates provided on the Reconsideration Background Data Form -MAXIMUS CHDR separately captures discrepancy data

Reconsideration Background Data Form Correcting Plan Error : 

Reconsideration Background Data Form Correcting Plan Error Corrections before report provided to CMS Do not send in new RBDF Provide information in writing to MAXIMUS CHDR Retain in file After timeliness report provided to CMS Send information to MAXIMUS CHDR and CMS MAXIMUS CHDR will not change data MAXIMUS CHDR will not re-run reports

Reconsideration Background Data FormCorrecting MAXIMUS CHDR Error : 

Reconsideration Background Data FormCorrecting MAXIMUS CHDR Error Send written notice to MAXIMUS CHDR MAXIMUS CHDR will research and report back to the Plan and CMS any errors made in recording data MAXIMUS CHDR will correct data errors MAXIMUS CHDR will not re-run report

Submitting New Case File : 

Submitting New Case File Must include completed Reconsideration Background Data Form Please separate multiple cases submitted in one package Expedited Cases – submit only NOI via fax MAXIMUS CHDR will not accept cases sent via facsimile

Submitting Additional Information : 

Submitting Additional Information Include case number and enrollee name Do not re-send Reconsideration Background Data Form as part of additional information submission Do not send medical records via facsimile

Reopening Requests : 

Reopening Requests Make reopening request in writing Not an automatic appeal for OT decisions Only granted when: Error on the face of the evidence, New information not previously available, or Fraud

MAXIMUS CHDR Enhanced Data Collection : 

Plan processing discrepancies Actual document (e.g. appeal letter, denial notice) RBDF Case narrative Organization Determination Notice Plan denial and decision reasons Enrollee arguments MAXIMUS CHDR Enhanced Data Collection

Data Reports : 

Monthly Reports Appeal receipt volume Data on disposition of completed cases Quarterly Reports Plan timeliness Compliance Reports Annual Reports Available through www.medicareappeal.com Data Reports

Quarterly ReportsPlan Processing Timeliness : 

Quarterly ReportsPlan Processing Timeliness Interval reported based on MCO supplied information in Reconsideration Background Data Form and date of case receipt Standard appeal cases assume 5 day period for mailing Expedited cases assume 1 day period for mailing

Quarterly ReportsCompliance Reports : 

Quarterly ReportsCompliance Reports Identifies whether MAXIMUS CHDR has received compliance statement for OT cases Notice sent to Plan by MAXIMUS CHDR Notice gives plan approx. 2 weeks to “correct” before reported to CMS

Slide 33: 

Quarterly Reports Compliance Reports – Helpful Hints Use Statement of Compliance included in OT decision Can send Statement of Compliance by fax MAXIMUS CHDR does not accept questionable compliance statements such as “planning to authorize” MAXIMUS CHDR will send questionable compliance statements to CMS RO

Slide 34: 

Appeals Data - Nation Cases Received by Category

Slide 35: 

Appeals Data – Region II Cases Received by Category

Slide 36: 

Appeals Data – Nation Cases Received by Case Class

Slide 37: 

Appeals Data – Region II Cases Received by Case Class

Slide 38: 

Appeals Data - MCO Mean Time Case Process (Days)

Slide 39: 

Appeals Data - MAXIMUS CHDR Mean Time Case Process (Days)

Slide 40: 

Appeals Data - Comparison % Cases in which RI Made

Slide 41: 

MAXIMUS CHDR Contact us at: medicareappeal@maximus.com 585-586-1770