medicaid managed care appeal process for providers€¦ · pa’s physical health managed care...
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Medicaid Managed Care Appeal Process for Providers2018 RCPA ANNUAL CONFERENCEFUELING THE FUTURE
PRESENTED BY: MARISSA LAWALL, JD, MARTIN LUTHER KING JR. FELLOWPENNSYLVANIA HEALTH LAW PROJECTOCTOBER __, 2018
About PHLPPHLP is a statewide, non‐profit law firm that provides free legal services to individuals having trouble accessing publicly‐funded health care coverage and services (e.g. Medical Assistance, CHIP, Waivers, etc.) .
Helpline: 1-800-274-3258 Email: [email protected]
www.phlp.org
PHLP: What we doProvide free legal services, community education, monthly newsletters, policy advocacy
Represent the interests of: ◦ individuals with disabilities◦ Lower‐income individuals◦ the elderly
On issues relating to accessing health insurance or health care services through publicly funded programs (Medical Assistance, Medicare, CHIP)
Goals for TodayBasic Understanding of the Appeals Process for Managed Care Organizations (MCOs) and Fee for Service (FSS)
What you can do as providers to make your patients aware of the appeal process when a service is denied
What PHLP can do to assist your patients with appeals and our referral process
The Basics
Acronyms•ALJ = Administrative Law Judge•BHA = Bureau of Hearings and Appeals•CAO = County Assistance Office•DHS = Department of Human Services (formerly DPW, Department of Public Welfare)•FSS = Fee for Service •MA = Medical Assistance (aka Medicaid) •MCO = Managed Care Organization (e.g Keystone First, Gateway, United GHP Family, etc.)
TerminologyoComplaint
• a dispute or objection about a participating provider, or about the coverage, operations, or management of the plan.
oGrievance • a request to reconsider a plan’s decision that a service or treatment is not medically necessary.
oExternal Review • Individuals who are not satisfied with a complaint or grievance decision can request a review by someone outside the plan.
oFair Hearings• In all grievance matters and in some complaints, you can request a Fair Hearing if you are unhappy with decision made by the MCO. This is the first step in FSS cases.
MA Delivery Systems1. Managed Care (HealthChoices) ◦ PA’s Physical Health managed care system is called HealthChoices◦ Almost all MA consumers must enroll in a Managed Care Organization (aka MCO or “plan”) and get all their care through that plan
◦ Kids in HIPP are exempt from Managed Care enrollment; stay in Fee for Service
2. Fee‐for‐Service (FFS) ◦ Consumers get care through straight ACCESS
Appeals Process
Advocating for your Patient•If you have prescribed something for your patient which you believe is indicated, and the insurance issues a denial, the best way to help your patient is to write an excellent letter of medical necessity and to participate in the fair hearing.•The patient does not need a lawyer, but does need the physician’s help, including clear medical record notes documenting the need.
Types of Appeals AvailableDepends on enrollment (FFS or MCO)
• If enrolled in MCO: have additional appeals availableoGrievance;oExternal Review; ANDoFair Hearing
• If enrolled in FFS: oFair Hearing is only appeal option available
Current Appeals Process
MCO service denial
First Level Grievance
External Review
DHS Fair Hearing
OMAP service denial
DHS Fair Hearing
Client in MCO Client in FFS/Access
What is an “appeal”?•An appeal is the term we use for the process by which a Medicaid beneficiary (i.e. our client/patient) challenges a coverage decision made by either: ◦ The Office of Medical Assistance Programs (OMAP) – for clients in Fee for Service; or
◦ The client’s Managed Care Organization (MCO)
When is there a right to Appeal?•Applicant’s claim for services is denied or not acted upon with reasonable promptness
•Beneficiary believes agency has acted erroneously in terminating, suspending, or reducing Medicaid eligibility
•Beneficiary believes agency (or MCO) has acted erroneously in terminating, suspending, or reducing Medicaid covered services (e.g. on grounds of medical necessity)
See 55 Pa Code § 275.1(a)(4)(i)
Why appeal?Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is part of federal Medicaid law & it mandates coverage of all medically necessary services for children under 21
Broad definition of medically necessary
DON’T TAKE NO FOR AN ANSWER!
Remember families may not realize they have a right to appeal, or may feel intimidated/daunted by the process.
This is where PHLP comes in!
Who can appeal?1. Individual in whose name benefits/services are sought 2. Parent of child under 18 (or legal guardian)3. Designated representative with written authorization
◦ MCO requires signed release unless guardianship or POA
4. Legal guardian ◦ At age 18, parent no longer legal guardian unless Guardianship obtained through court.
Note: PHLP does NOT handle Guardianship or Power of Attorney
Who can appeal? (continued)5. “Agents” under a Power of attorney
◦ Can be limited in scope: “to pursue appeals” / “to pursue benefits”
◦ Legal wording found at 20 Pa.C.S. § 5602
◦ Even persons w/ ID can grant POA if they can indicate intent to have a specific person make decisions on their behalf.
◦ POA allows parent to handle appeal without depriving young adult of their legal rights.
Two Issues for AppealIn general, Medicaid appeals involve two broad issues:
1) Medicaid applicants appealing the state agency’s decision to deny their eligibility for Medicaid; or
2) Medicaid beneficiaries appealing the state agency or MCO’s decision to deny or discontinue coverage of particular services
Medical Necessity•Denied services, or services requiring prior authorization, must bemedically necessary.Medical necessity is a legal, not a medical, definition.•Under Pennsylvania Medical Assistance, a service ismedically necessary if it meets any one of the three standards below:1) The service or benefit will, or is reasonably expected to, prevent the onset
of an illness condition, or disability2) The service or benefit will, or is reasonably expected to, reduce or
ameliorate the physical, mental, or developmental effects of an illness, condition or disability, or
3) The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.
Legal Protections•Goldberg v. Kelly (1970) ‐ Due Process Clause of the 14th Amendment requires a hearing before a recipient of gov’t benefits can be deprived of benefits◦ “Government benefits” includes Medical Assistance (Medicaid) coverage & services!
•Medicaid insurer may not deny, stop, reduce, change services without first providing:◦ NOTICE; and
◦ An OPPORTUNITY TO BE HEARD (i.e. a hearing)
Legal Protections: Notice Required•Notice must be sent in writing
•Sent in advance of decision taking effect •Must contain reason for denial, reference to policy, clinical facts underlying decision
•Must provide instructions on how to appeal; how to appeal to keep services in place while appeal is pending
Sample Denial Notice(MCO)
Sample Denial Notice (FSS)
Legal Protections: Hearing RequiredOpportunity to be heard
Opportunity to present case to neutral decision‐maker who decides whether decision was proper or not
This means a Fair Hearing, or a Grievance and a Fair Hearing (for those enrolled in MCO)
Legal Protections: Continued Benefits Pending Appeal •Filing an appeal within 10 days of denial gives client the right to keep current services in place until that level appeal is resolved
•Applies to all levels of appeal, so long as file appeal within 10 days at every level
•Strong legal protection for our clients
Continued Benefits Pending Appeal•Appealing a partial denial is NOT a “rejection” of the authorized hoursoE.g. Request for SN 8 hrs/night 7x per week and 4 hrs/day M‐F. MA partially denies: authorizes SN 8 hrs/night 7x per week, denies 4 hrs/day M‐F. Parent appeals. During appeal, client has right to the 8 hrs/night, issue for appeal is the 4 hrs/day M‐F that were denied
•Some MCOs may claim client doesn’t get to use the 8 hrs overnight because filing an appeal is like a rejection of the authorized hours. =
Note: common confusion among MCOs; Refer to PHLP for help if this happens
LOOK FOR THIS LANGUAGE IN DENIAL NOTICE
Grievance & External Review
Grievance Hearings• “A request by an enrollee . . . to have a managed care plan . . . reconsider a
decision solely concerning the medical necessity and appropriateness of a health care service.” 28 Pa Code § 9.602
• A grievance may be filed regarding any of the following: ▫ MCO denies a requested health service in whole or part▫ MCO approves a requested service for a lesser scope or duration than requested
▫ MCO denies a requested health care service but approves an alternative health care service
• Doctors employed by the MCO decide grievances
How to Request a GrievanceCall MCO member services; or mail or fax a letter (or form‐coming soon!)
Within 60 days of date on denial letter or 10 days to keep current services in place pending appeal
Coming soon:Grievance Request Form
Grievance Timeline •After calling, MCO must send written acknowledgement of grievance with instructions for next steps
•Grievance proceeding held & decision issued within: ◦ 30 days for 1st Level Grievance;◦ 45 days for 2nd Level Grievance
Upcoming change: ◦ Grievance proceeding will be held & decision issued within 30 days of request
•Right to participate in grievance by phone or in person◦ Must call MCO to let them know wish to participate◦ Otherwise, MCO can & will hold grievance without client◦ Meetings held at locations in each HealthChoices Zone
In Person Grievance LocationsAetna Better Health • Southeast: Philadelphia
• Lehigh/Cap: Allentown, Harrisburg
AmeriHealthCaritas/Northeast
• Lehigh/Cap: Harrisburg, Clearfield • New East: Scranton
Gateway • Lehigh/Capital: Camp Hill, Harrisburg• Southwest: Pittsburgh• New West: W. Middlesex, Grove City
Geisinger • New East: Danville, Wilkes Barre
In‐Person Grievance LocationsHealthPartners • Southeast: Philadelphia
Keystone First • Southeast: Philadelphia
United • Southeast: Philadelphia• Lehigh/Cap: Lancaster • Southwest: Pittsburgh
UPMC for You • Lehigh/Cap: Camp Hill• Southwest: Pittsburgh• New West: Erie
Preparing for the Grievance•Request a copy of all documentation and information MCO looked at to make decision.
oMCO must provide this case file to member at no charge
•Submit additional documentation to MCO appeal office prior to grievance meeting
oNot sent to prior auth office!
oPHLP can provide appeals fax #s if needed
Grievance Accessibility Requirements•MCO must accept grievances from members with disabilities in alternative formats including: TTY/TDD for those with hearing impairment; Braille; tape; or computer disk; and other commonly accepted alternative forms of communication.
•MCO must provide members with disabilities assistance in presenting their case at the Grievance at no cost
Grievance Accessibility Requirements (Con’t)•This includes:
a. Providing qualified sign language interpreters;
b. Providing information submitted on behalf of the MCO at the Grievance review in an alternative format accessible to the member; and
c. Providing personal assistance to Members with other physical limitations in copying and presenting documents and other evidence.
What happens at the grievance?•At the grievance meeting, a summary of the case is presented by MCO, then family given the chance to state their case•Helpful to have CM and/or doctor participate to discuss clinical matters re: medical necessity •Written decision sent w/in 5 business days of the meeting•Decision letter must include: issue on appeal; decision; reasons for decision applied to facts of case, any authority or policy, guidelines, etc. relied upon; and how to appeal (if service remains denied).
Expedited Grievance•If waiting normal timeframe for Grievance decision would be harmful, member can request expedited grievance. •Available if provider certifies in writing that: ◦ The “member’s life, health or ability to attain, maintain or regain
maximum function would be placed in jeopardy by following regular appeal process.”
◦ Standard is not “life or death.”
• Provider certification due within 3 business days of member’s request for expedited grievance.
• PHLP can provide template Provider Certification letter
Expedited Grievance Hearing•If request for expedited grievance is granted, MCO will hold grievance meeting by phone & make decision within: o48 hours of their receipt of doc’s letter; or
o3 business days from receipt of client’s request for expedited grievance, whichever is shorter.
•Same right to participate in grievance
•Decision will be provided by phone, followed up in writing within 2 days
Grievance Win•Language to look for “Denial overturned”•MCO is bound by decision ‐ cannot appeal decision of their own grievance committee•If MCO fails to promptly implement its own grievance decision (or implement its decision at all), contact PHLP•Grievance decision not binding on future auth requests for same service
Grievance Loss•Language to look for “Denial upheld”•Request External Review and DHS Fair Hearing •File these next two appeals within 10 days of date of grievencedecision to receive continued benefits pending appeal!
External Review•Request in writing or by calling MCO, within 15 days of grievance decision or10 days for continuity to apply •Review of grievance decision, performed by a Certified Review Entity (CRE) not affiliated with the MCO• MCO sends file with everything from grievance to CRE• Family can (should) submit documents to CRE. Copy to MCO!
•No meeting held ‐ just a review of documents•Decision takes up to 60 days•Can be expedited, but only if the grievance was expedited.
• Does not require another doctor certification• The enrollee has 2 business days from the receipt of the expedited internal review decision to contact the plan to request an expedited external review.
MCO Procedural Errors•Failure to send timely notice
•Failure to include correct details in denial notice (reason for denial, policy cite, facts underlying finding, etc.)
•Not allowing member to participate in grievance meeting • Or parent shows up for “in person” grievance and committee is conferenced in by phone.
•No grievance decision within 30 days (first level) or 45 days (second level)•Taking longer than 48 hours to make authorization decision (“pended for more info”)
DHS Fair Hearing
Fair Hearings•Request in writing within 30 days of most recent denial, or within 10 days to keep continuity in place• POSTMARK date = date of request
•Instructions on notice
•PHLP has template request letters
•Hearing held & decision issued within 90 days Administrative Law Judge (ALJ) hears both sides & issues decision a few weeks after hearing held.
What to include in Fair Hearing Request
Where to send Fair Hearing RequestIf enrolled in Fee for Service, send Fair Hearing request letter to:
Department of Human ServicesOffice of Medical Assistance Programs Complaint, Grievance and Fair Hearings PO Box 2675 Harrisburg, PA 17105‐2675
If enrolled in MCO, send Fair Hearing request letter to:
Department of Human ServicesBureau of Fee‐for‐Service Programs ATTN: Recipient Appeals Section PO Box 8050 Harrisburg, PA 17105
In Person Hearing Locations
Western 2 Gateway Center, Suite 1125 Pittsburgh, PA 15222‐3594
1001 State Street, Suite 401 Erie, PA 16501
Northeast 117 W. Main Street Plymouth, PA 18651
Central 2330 Vartan Way, Second Floor Harrisburg, PA 17110‐9721
625 Cherry Street, Room 440 Reading, PA 19602‐9985
Southeast 801 Market Street, Suite 5005 Philadelphia, PA 19107
Expedited DHS Fair Hearing•Only available to MCO enrollees, not FFS•Same harm standard and doc’s certification letter required (see Expedited Grievance slides)
•Once expedited, hearing is held by phone & decision made within 48 hours of receipt of doc’s certification letter or 3 business days of member’s request, whichever is shorter.
•If certification not received, decision within normal 90 day process.•Many ALJs hold an initial “mini hearing “to decide whether expedited is appropriate, based on doc’s certification letter
•Doc can testify at hearing to explain why harmful to wait, in addition to providing letter
Interim Relief•If no FH decision within 90 days of date appeal was filed, entitled to “interim relief” for services & supplies other than 1 time items like DME. See 55 Pa. Code § 275.4(d).•If family has been waiting longer than 90 days for a hearing, send them to PHLP so we can help with Interim Relief request.
Win at DHS Fair Hearing •ALJ has power to enforce hearing decision after the hearing – call PHLP if MCO not abiding by hearing decision
•OMAP or MCO may appeal the fair hearing decision by filing for “Reconsideration”oReconsideration must be requested within 15 days from date of fair hearing decision
oEssentially asking Secretary to review ALJ’s decision and decide if appropriate•Secretary will either agree to reconsider or not; if agrees then will issue preliminary “Order Granting Reconsideration
•If Secretary accepts MCO’s Reconsideration request, family has 15 days to respond.
•If appeal was for ongoing services & family won, agency must provide those services while final Order on Reconsideration is pending. See Moseley v. DPW, 598 A.2d 317 (1971)
Loss at DHS Fair Hearing•Family has 15 days from date of hearing decision to file “Application/Petition for Reconsideration”
•Form is included with hearing decision
•Same procedures/standards as when OMAP/MA or MCO asks for Reconsideration when the family is successful
MCO Procedural Errors•Failure to send written decision notice, acknowledgment letter, scheduling letter •Refusal to accept grievance request by phone•Refusal to provide client with a copy of appeal case file•Grievance not properly recorded in system•Classifying an appeal as a rejection of partial authorization•Failure to auth continuity of services pending appeal•Problems with in‐person grievances (all panel members by phone, e.g.)
Role of the Provider
Peer to Peer Review•Apart from client’s individual appeal right, doctor has opportunity to discuss request with plan Medical Director, called a “Peer to Peer”•If during Peer to Peer, the prescribing doc is persuaded to change the amount or type of service he/she is prescribing, client’s appeal is effectively nullified•Takeaway:
oEncourage doctors to pursue peer to peeroNot an alternative to client filing their own appeal (Grievance) oBUT, encourage docs to stick up for request during peer to peer!
Fair Hearing• A hearing before an ALJ; sometimes the MCO or department is represented by a physician.•Helps if providers testifying on behalf of patients.•Testimony would include:
oDiagnosesoMedical Necessity opinion (including a letter)oCare and skill level required for treatment
Letter of Medical Necessity
A template for a letter of medical necessity can be found on our website at www.phlp.org
How Providers can help PHLP•Provide documentation to PHLP for review: LOMN, nursing notes, med/PRN charts, clinical assessments, school letters•We will likely ask for what was already submitted with prior auth request as well as UPDATES to clinicals during appeal process
•Clinical consultant for PHLP lawyers •Help us to obtain LOMNs•Providers as witnesses at appeal hearings ‐ VERY helpful!
How PHLP Can Help•If you refer patients to PHLP, we can:
oDiscuss options with clients and assist them in appealing denialsoRepresent individuals and families, if appropriate, at grievance and fair hearings
oAssist you in writing Letters of Medical Necessity
PHLP Success StoryA 10 year old, Medically Fragile, child was denied skilled nursing hours provided by a home health agency by the MCO. The MCO felt that despite her complex medical diagnosis a home health aid could provide adequate care and in the event she needed more care her mom, who worked from home could care for her. The mom represented herself in a grievance hearing and the decision was upheld.All of the providers disagreed with this outcome. The home health agency contacted us to find out what we could do. We assisted in appealing to for a fair hearing. We worked with the doctors, and home health agency to get medical records, understand the diagnosis, and the care required. We also assisted in preparing letters of medical necessity and prepping the clinical manage, who testified on behalf of the child.We took the case to a Fair Hearing, and were successful in securing skilled nursing hours.
Thank you!Marissa Lawall, JD
Martin Luther King Jr. Fellow
Pennsylvania Health Law Project
Phone: 215‐625‐ 3990 x121
Fax: 215‐625‐3879
Toll Free Helpline: 1‐800‐274‐3258