C2C Innovative Solutions, the Medicare appeals contractor who processes all DMEPOS appeals at the second level, also known as reconsideration, has announced implementation dates for its expansion of the formal telephone discussion demonstration. This program, currently limited to DMEPOS claims in Jurisdiction C and D, will be expanded to include claims for orthoses as of February 17th and claims for prostheses as of March 17th. Claims for therapeutic shoes were added as of January 17th.
The formal telephone discussion demonstration is an opportunity for providers to interact directly with the medical review staff at C2C in an attempt to resolve issues that caused the claim to be denied by the DME MAC and subsequently denied at the redetermination level of the appeal process. To date, the demonstration has proven to be very successful with a denial overturn rate approaching 86%.
The recent announcement of the expansion of the program to both orthotic and prosthetic services provides a welcome opportunity to potentially avoid the significant delay and backlog that currently exists at the Administrative Law Judge (ALJ) level of the appeals process. Unfortunately there is no way to “sign up” for this program. Your claim(s) must be selected for review by representatives of C2C solutions. In addition, because this program was established as a demonstration project, there must be a study group (Jurisdiction C and D) and a control group (Jurisdiction A and B). As a result, it is unlikely that the demonstration project will be expanded beyond Jurisdiction C and D.
In addition to the announcement of the expanded program, C2C has indicated that they have been authorized by CMS to overlook some common reasons for claim denial if the whole of the records support the medical need for the claim. An example of this authority is the ability to overturn denials based on a missing signature on a medical record. Cases where medical necessity is lacking will continue to be denied at reconsideration.
Overall, this is a tremendous opportunity for O&P providers and AOPA members who are contacted by C2C with an invitation to participate should take full advantage of the opportunity. Read the summary of Medicare appeals final rule here.
Questions regarding this issue may be directed to Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org