by Gregory A. Cardenas
Sections 1869 and 1879 of the Social Security Act provide Medicare Beneficiaries and, under certain circumstances, providers and suppliers of health care services, an appeals process for determinations regarding claims for benefits under Medicare Parts A and B. The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 ("BIPA") substantially revised this Medicare claim appeals process. The new appeals provisions are effective for initial determinations made on or after October 1, 2002. Among the major changes required by the BIPA Amendments are (i) a uniform process for handling Medicare Part A and B appeals; (ii) revised time frames for filing an appeal and for certain redeterminations made by contractors who made the initial determination; (iii) the establishment of a new appeals entity, the qualified independent contractor ("QIC") to conduct "reconsiderations" of contractors' initial determinations; (iv) the establishment of a uniform amount in controversy threshold of $100 for appeals at the ALJ Level; (v) a 90 day time limit for conducting ALJ and MAC appeals; and (vi) "de novo" review when the MAC reviews an ALJ decision made after hearing. The BIPA Amendments also require that the Secretary establish a process by which an individual may obtain an expedited determination after receipt of a notice from a provider of services that the provider plans to terminate services or discharge the individual. Currently, this right only exists with respect to hospital discharges. On November 15, 2002, CMS published a 51 page proposed rule setting forth the regulations that would be needed to implement these new statutory provisions. CMS will consider comments to the proposed rule that are received no later than 5 p.m. on January 14, 2003.This material is not intended to create, and does not create, an attorney-client relationship between you and Vinson & Elkins L.L.P., and you should not act or rely on any of this information. As legal advice must be tailored to the specific circumstances of each case, nothing provided herein should be used as a substitute for advice of competent counsel. These materials do not constitute legal advice, do not necessarily reflect the opinions of Vinson & Elkins L.L.P. or any of its attorneys or clients, and are not guaranteed to be correct, complete, or up-to-date.
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