Appeals and Grievances: CMS Guide for Facilities
The Centers for Medicare and Medicaid Services (CMS) provide healthcare coverage to more than 60 million individuals across the nation. If you manage a long-term care facility, you likely coordinate with CMS in transactions regarding Medicare beneficiaries on a regular basis. It’s understandable to have questions about billing, appeals and grievances, CMS requirements, and other related CMS categories.
The appeal and grievance processes are an important part of Medicare billing, as they may be necessary to maintain coverage for patient care. In this article, we’ll explain the difference between appeals and grievances and describe the basic appeal and grievance processes defined by CMS.
What Are Appeals and Grievances?
CMS and its contractors process more than 1 billion Medicare claims annually. With this broad scope, it’s no surprise that beneficiaries disagree with reimbursement decisions from time to time. CMS outlines processes for such instances.
An appeal is the process of challenging decisions made by CMS regarding Medicare or Medicaid coverage and reimbursement. Appeals may be prompted if CMS denies a claim, reduces reimbursement, or makes a decision that negatively impacts the rights or financial interests of the involved party. A medical provider can also file an appeal on behalf of a patient.
Example: A skilled nursing facility (SNF) submits a claim for a service provided to one of their patients, CMS denies it, stating that the service is no longer medically necessary. The patient and their family disagree and choose to file an appeal with CMS.
A grievance — also referred to as a complaint — is a concern raised by a Medicare or Medicaid beneficiary about their care. CMS grievance categories include the length of time it takes to access treatment, customer service, and other quality of care concerns. While appeals focus on specific decisions made by CMS, a grievance is more broad and will not reverse a coverage denial.
Example: A Medicare beneficiary finds it extremely difficult to access appropriate care from their provider. Their appointments are repeatedly canceled and when they finally settle on a time, they face long wait times. After raising their concerns with the provider, they still experience unsatisfactory access to care and choose to file a grievance.
Appeals and Grievances: CMS Process Explained
As part of the Medicare billing process, your facility will be connected with a Medicare Administrative Contractor (MAC) who is responsible for reviewing your billing claims, checking for accuracy and compliance, and issuing decisions about reimbursement. These decisions are known as CMS organization determinations — they may pertain to prior authorization for a service or item, a specific payment amount, or a decision about the quantity of approved items.
If a patient or provider disagrees with a CMS determination, they can initiate an appeal. There are five levels to the appeals process.
- MAC redetermination: File a redetermination request to your MAC within 120 days of receipt if you disagree with an initial CMS decision.
- QIC reconsideration: If you’re dissatisfied with the redetermination decision, file a reconsideration within 180 days. Your case will be reviewed by a Qualified Independent Contractor (QIC) who was not involved in the original decision.
- OMHA decision: At this level, you’ll explain your situation to an Administrative Law Judge (ALJ) as part of the Office of Medicare Hearings and Appeals (OMHA). File your appeal within 60 days after the reconsideration decision has been made.
- Council review: You can request a review from the Medicare Appeals Council within 60 days of the ALJ’s decision. The council can either uphold the decision, issue its own determination, or send the case back to the ALJ for further review.
- District court review: If you disagree with the council’s findings, submit a judicial review request within 60 days. This will send the appeal to a Federal District Court, which will make a final determination.
To help the appeal process go smoothly, be sure to submit all appeal requests in writing within the allotted time limit. Include copies of relevant documents, such as decision letters and claim information issued at previous levels.
When it comes to appeals and grievances, CMS recognizes that some beneficiaries may need timely feedback. For example, a patient or provider might disagree with a CMS decision to end coverage for services actively being provided by a hospital, long-term care facility, hospice, or outpatient facility. In these instances, concerns must be addressed more quickly than through the formal appeal process.
Once a patient receives written notice that their services will be ending, they can request a fast appeal from the Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) assigned to their state. This independent third party will promptly review the case and issue an expedited decision by the close of the business day after it receives all required information.
CMS guidelines for complaints and grievances require that official grievances be filed to the healthcare plan no later than 60 days after the event or incident in question. Grievances can be submitted verbally or in writing, and may or may not specify requested corrective action.
Then, a representative for the healthcare plan will review the grievance and gather information, and may request additional documentation from the beneficiary. After the investigation, the plan will seek meaningful resolution for the issue and send a written response to the beneficiary about their decision.
According to CMS grievance response requirements, the health plan must communicate its decision within 30 days. In some cases, they may be required to reply sooner if the beneficiary’s medical condition would be adversely impacted by a delayed response.
If beneficiaries are dissatisfied with the proposed resolution, they can request a review from a state agency or choose to reach out to a healthcare ombudsman to assist in mediating their issue.
Gain Insight to Lead With Confidence
Although we’ve helped explain appeals and grievances, CMS processes probably aren’t the only topic you’re wondering about as you manage your facility. Uncover the industry insights and advice you need to lead confidently with free access to the IntelyCare newsletter.