CMS Proposes Alteration of Billing Number Appeals Process

BALTIMORE–Home medical equipment providers whose supplier
numbers have been revoked or denied would be entitled to a hearing
before an administrative law judge under a CMS proposal that was
published in Friday’s Federal Register.

The proposal for changes to the agency’s current policy would
also entitle those providers to a subsequent departmental appeals
board review and judicial consideration of the board’s
decision.

CMS said the proposal is an effort to “clarify, expand and
update our current policy and administrative appeals rights.” It
would, the agency said, give providers “a measure of protection
against adverse actions by us and extend protection to a larger
group of suppliers beyond the [durable medical equipment] providers
currently covered.”

The proposed regulation would also cover independent
laboratories, ambulance providers, independent diagnostic testing
facilities, physicians and other entities.

“In my opinion, this is a great expansion of the current policy
as providers would have the ability to plead their case to an
independent person,” said Sarah Hanna, a reimbursement consultant
and vice president of ECS Billing & Consulting, Tiffin, Ohio.
“Prior to this, if [an] application was denied or revoked, the
provider had no appeal options.”

The current regulation only entitles providers to a Medicare
carrier hearing and the option of seeking a review before a CMS
official.

The proposal would also require Medicare carriers to notify
providers of their billing number revocations or denials by
certified mail and include the reason for the denial or revocation
“in sufficient detail to allow the supplier to understand the
nature of its deficiencies.” The provider must also be informed of
the right to appeal and the address to which the written appeal
must be mailed, according to the proposal.

“It does clarify the process,” observed Brian Miller, an
attorney with the Health Law Center in Greenville, S.C. “But not
all of the clarifications are beneficial [to providers].”

Miller said the new proposal “dumbs down” the notice
requirements and also eliminates the current requirement that a
hearing be held within one week of a request. While Miller said CMS
has seldom honored the one-week hearing stipulation, “I think
dumbing down the one process and delaying the hearing are
potentially detrimental [to providers].”

But a third key feature is to providers’ benefit, he said. CMS
is proposing that if a revocation of a provider’s billing
privileges is reversed upon appeal, those privileges would be
reinstated “back to the date that the revocation became
effective.”

“They’re guaranteeing retroactive reinstatement” of billing
privileges, Miller said.

The proposal also alters timeframes for providers to file
appeals of an adverse determination. Providers would have 60 days
to file an appeal rather than the current 90 days; the proposed
maximum adjudication timeframe for appeals would be 180 days,
except in the case of reconsideration, when it would be 60
days.

The proposal also suggests reducing the time from 60 to 30 days
for a provider to furnish complete information requested by a
contractor or all supporting documentation in submitting an
enrollment application.

Comments on the proposal will be accepted until May 2. To
comment electronically, visit http://www.cms.hhs.gov/eRulemaking and select
docket ID CMS-6003-P.