BALTIMORE--Home medical equipment providers whose supplier numbers have been revoked or denied would be entitled to a hearing before an administrative law judge under a CMS proposal that was published in Friday's Federal Register.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

Want to use this article? Click here for options!
© 2007 Penton Media, Inc.