Business Process Management for Government Helping Government Serve the People. MAXIMUS Federal Services RAC Summit December 5, 2013
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1 Helping Government Serve the People MAXIMUS Federal Services RAC Summit December 5, 2013
2 MAXIMUS Federal Services RAC Summit QIC Program MAXIMUS Federal Services QIC Part A Appellant Tips/Best Practices
3 Medicare Appeal Process 5 Levels of Appeal
4 QIC History Established in BIPA (2000) Modified by MMA (2003) QIC projects initially competed in 2004 AdQIC Part A East/West Part B/DME
5 MAXIMUS Federal Services QIC Projects Fee For Service QICs AdQIC Part A East (2005) Part A West (2008) Part B South (2005) Managed Care QICs Part C (2006) plus prior IRE Contract (1989) Part D (2005)
6 MAXIMUS Federal Service QIC Projects QIC Programs Organization Chart
7 MAXIMUS Federal Services QIC Projects Fun Facts We process more than 10.1 million pages of documents in one month. MAXIMUS Federal QICs have processed roughly 3 million claims. In 2013, MAXIMUS Federal QICs will receive appeal requests for almost 1 million claims. In 2013, QIC Part A processed in one month, the volume it processed for the entire 2011 calendar year.
8 MAXIMUS Federal Services QIC Part A
9 MAXIMUS Federal Services QIC Part A Combined Adjudication Staff Clinical Adjudicators Licensed clinical staff including RNs, LPNs Therapists Technical Adjudicators Physician Reviewer Board certified and credentialed
10 MAXIMUS Federal Services QIC Part A Combined Staff (continued) Subcontractors Medical Review Panel Board certified, credentialed physicians Credentialed nurses and therapists Average MFS review experience > 3 years Three CMS approved subcontractors Provide combination of first and second reviews Staff trained and decisions subject to MFS quality review
11 MAXIMUS Federal Services QIC Part A Acknowledge appeal request receipt within 7 days. Request case file from first level reviewer within 14 days. Provide clinical review, if not fully favorable to appellant case must also be reviewed by Physician Reviewer. Render decision within 60 days of appeal request receipt. Provide escalation information for those cases >60 days. Send written decision to appellant.
12 MAXIMUS Federal Services QIC Part A Timeliness
13 MAXIMUS Federal Services QIC Part A Volume
14 MAXIMUS Federal Services QIC Part A
15 MAXIMUS Federal Services QIC Part A Volume
16 MAXIMUS Federal Services QIC Part A Volume
17 MAXIMUS Federal Services QIC Part A Volume Unexpected Volume Demonstration project low volume of appeals. Volume estimate, based on available data, was 87,000 appeals for Volume continues to be unpredictable Need additional data to develop model to reliably predict the appeal requests. Reconsideration timing: up to 180 day lag between MAC decision and appeal request.
18 MAXIMUS Federal Services QIC Part A Volume Increased adjudication and operations staff. Focused, in depth training and mentoring. Decisions subject to 100% quality review in while in training. Monthly quality review samples. Contracted with CMS approved subcontractors. Focused, in depth training and mentoring. Decisions subject to 100% quality review in while in training. Monthly quality review samples.
19 MAXIMUS Federal Services QIC Part A Volume Expanded Office Space Opened satellite office. Within one year almost doubled the square footage in our Pittsford NY location. Increased cubicle footprint in other Part A locations. Revised workflow process Clerical functions consolidated. Team specialization emphasized.
20 QIC Part A Volume Highlights Eliminated available backlog while addressing the incoming volume. Returned to required timeliness within Maintained high quality throughout 2012 and 2013.
21 MAXIMUS Federal Services QIC Part A Volume
22 Tips for working with MAXIMUS Federal Services QIC Part A
23 MAXIMUS Federal Services QIC Part A Tips How to file Reconsideration Request Determine Part A Jurisdiction based on location in which services were provided. Do not rely on name of RAC Use CMS Standard Reconsideration Request Form CMS Send written Request to correct address
24 MAXIMUS Federal Services QIC Part A Tips PART A EAST Alabama, Arkansas, Colorado, Connecticut, Delaware, Florida, Georgia, Louisiana, Maine, Maryland, Mississippi, Massachusetts, New Hampshire, New Mexico, New Jersey, New York, Texas, Oklahoma, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, Tennessee, Vermont, Virgin Islands, Virginia, West Virginia, and Washington DC Mail to: Maximus Federal Services Medicare Part A East 3750 Monroe Avenue Suite 701 Pittsford, NY
25 MAXIMUS Federal Services QIC Part A Tips PART A WEST Mail to: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Ohio, Oregon, South Dakota, Utah, Washington, Wisconsin and Wyoming Maximus Federal Services Medicare Part A East 3750 Monroe Avenue Suite 706 Pittsford, NY
26 MAXIMUS Federal Services QIC Part A Tips Reconsideration request must contain complete information, including: Beneficiary s name HICN Service/item in dispute Dates of service Name and signature of party or representative Redetermination contractor name Provide any additional documentation identified in Redetermination to support Medicare coverage criteria.
27 MAXIMUS Federal Services QIC Part A Tips Appointment of Representation (AOR) CMS will be updating IOM and QIC Manual Latest guidance: Provider does not need to identify beneficiary Provider s National Provider Indicator Number required CMS Form CMS 1696 is preferred form If Provider is representing beneficiary and has already provided services, then provider must complete Waiver of Payment
28 MAXIMUS Federal Services QIC Part A Tips Steps MFS takes to cure defective AOR Provide Appellant notice of defective AOR Notice is sent to Appellant and Representative Appellant/Representative has 14 days to correct the AOR Corrected notice returned to MFS Faster processing if provide correct Reconsideration appeal number when returning the form Corrected form associated to file and coverage review proceeds If corrected AOR not received, then the appeal is dismissed.
29 MAXIMUS Federal Services QIC Part A Tips Missing AOR No AOR means representative lacks authority to act on behalf of the provider No AOR means representative cannot obtain or receive any information related to the appeal. Contractor shall provide notice that AOR is missing No reconsideration will be performed until valid written AOR is received. Appeal request is subject to dismissal
30 MAXIMUS Federal Services QIC Part A Tips MAXIMUS Federal Customer Service Part A East: Part A West: QIC Part A Website
Income from U.S. Government Obligations
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