In recent blogs, we outlined medical Medicare review strategies; explained probe and educate (PE), as well as Targeted Probe and Educate (TPE), Medicare’s new medical review strategy; we offered strategies for preparing and submitting TPE documentation; we outlined the TPE claims review process; and we highlighted top hospice TPE denial reasons. In this blog, we will share some TPE appeal options and recommendations.
If your hospice agency’s TPE claim is denied or partially denied, you can utilize the 5 Levels of Appeal process. We explain each level in detail below.Level 1 – Redetermination by a Medicare Administrative Contractor (MAC)
This entails a written request, submitted within 120 days from the date of receipt of the Remittance Advice that lists the initial determination. To initiate a MAC redetermination, your hospice agency must attach any supporting documentation to the redetermination request. MAC staff unassociated with the initial claim determination will perform the redetermination. A decision is usually made within 60 days of the request.
Level 2 – Reconsideration by a Qualified Independent Contractor (QIC)
This Level 2 appeal entails a written request, submitted within 180 days from the date of receipt of the Medicare Redetermination Notice (MRN) or Remittance Advice (RA). This request must clearly explain why your hospice agency disagrees with the redetermination decision. It is your last opportunity to add supporting documentation for consideration. A “Medicare Reconsideration Notice” will arrive about 60 days after the QIC receives this Level 2 appeal request.
Level 3 – Hearing before an Administrative Law Judge (ALJ)
The ALJ hearing gives you (and by extension, your hospice agency) the opportunity, via video teleconference, telephone or occasionally in person, to explain your position to an ALJ. Your agency must file a request within 60 days of receipt of the reconsideration letter, or after the expiration of the reconsideration period. A decision is usually made within 90 days of the request.
Level 4 – Review by the Medicare Appeals Council
A Level 4 appeal must be filed within 60 days of receipt of the ALJ’s decision, or after the ALJ ruling time frame expires. In it, your agency must explain which part of the ALJ decision you disagree with. A decision is issued within 90-180 days from receipt of a request for review.
Level 5 – Judicial review in U.S. District Court
A Level 5 appeal must be filed within 60 days of receipt of the Appeals Council’s decision, or after the Appeals Council ruling time frame expires. You may only request judicial review if a certain dollar amount remains in controversy following the Medicare Appeals Council decision.
Tips on Appealing Claims
Routinely check DDE track appeal responses.
Adhere to time frames.
Submit a cover letter with TPE responses.
Do not stop billing.
Appeal all claims.
Track your appeals.
Appoint a person to write initial appeals. Clearly state your case.
Whenever possible, use the language of the Conditions of Participation (CoPs), limited coverage determination (LCDs) and published articles.