Appeals and Grievances: CMS Guide for Facilities

The Centers for Medicare and Medicaid Services (CMS) provides healthcare coverage to more than 60 million individuals across the nation. If you manage a long-term care facility, you likely coordinate with CMS in transactions regarding Medicare beneficiaries on a regular basis. It’s understandable to have questions about billing, appeals and grievances, CMS requirements, and other related CMS categories.

The appeal and grievance processes are important aspects of Medicare billing, as they may be necessary to maintain coverage for patient care. In this article, we’ll explain the difference between appeals and grievances and describe the basic appeal and grievance processes defined by CMS.

What Are Appeals and Grievances?

CMS and its contractors process more than 1 billion Medicare claims annually. With this broad scope, it’s no surprise that beneficiaries disagree with reimbursement decisions from time to time. CMS outlines processes for such instances.

Appeals

An appeal is the process of challenging decisions made by CMS regarding Medicare or Medicaid coverage and reimbursement. Appeals may be prompted if CMS denies a claim, reduces reimbursement, or makes a decision that negatively impacts the rights or financial interests of the involved party. A medical provider can also file an appeal on behalf of a patient.

Example: A skilled nursing facility (SNF) submits a claim for a service provided to one of their patients, CMS denies it, stating that the service is no longer medically necessary. The patient and their family disagree and choose to file an appeal with CMS.

Grievances

A grievance —; also referred to as a complaint — is a concern raised by a Medicare or Medicaid beneficiary about their care. CMS grievance categories include the length of time it takes to access treatment, customer service, and other quality of care concerns. While appeals focus on specific decisions made by CMS, a grievance is more broad and will not reverse a coverage denial.

Example: A Medicare beneficiary finds it extremely difficult to access appropriate care from their provider. Their appointments are repeatedly canceled and when they finally settle on a time, they face long wait times. After raising their concerns with the provider, they still experience unsatisfactory access to care and choose to file a grievance.

Appeals and Grievances: CMS Process Explained

Appeals

As part of the Medicare billing process, your facility will be connected with a Medicare Administrative Contractor (MAC) who is responsible for reviewing your billing claims, checking for accuracy and compliance, and issuing decisions about reimbursement. These decisions are known as CMS organization determinations — they may pertain to prior authorization for a service or item, a specific payment amount, or a decision about the quantity of approved items.

If a patient or provider disagrees with a CMS determination, they can initiate an appeal. There are five levels to the appeals process, which are outlined in the table below.

To help the appeal process go smoothly, be sure to submit all appeal requests in writing within the allotted time limit. Include copies of relevant documents, such as decision letters and claim information issued at previous levels.

Fast Appeals

When it comes to appeals and grievances, CMS recognizes that some beneficiaries may need timely feedback. For example, a patient or provider might disagree with a CMS decision to end coverage for services actively being provided by a hospital, long-term care facility, hospice, or outpatient facility. In these instances, concerns must be addressed more quickly than through the formal appeal process.

Once a patient receives written notice that their services will be ending, they can request a fast appeal from the Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) assigned to their state. This independent third party will promptly review the case and issue an expedited decision by the close of the business day after it receives all required information.

Grievances

CMS guidelines for complaints and grievances require that official grievances be filed to the healthcare plan no later than 60 days after the event or incident in question. Grievances can be submitted verbally or in writing, and may or may not specify requested corrective action.

Then, a representative for the healthcare plan will review the grievance and gather information, and may request additional documentation from the beneficiary. After the investigation, the plan will seek meaningful resolution for the issue and send a written response to the beneficiary about their decision.

According to CMS grievance response requirements, the health plan must communicate its decision within 30 days. In some cases, they may be required to reply sooner if the beneficiary’s medical condition would be adversely impacted by a delayed response.

If beneficiaries are dissatisfied with the proposed resolution, they can request a review from a state agency or choose to reach out to a healthcare ombudsman to assist in mediating their issue.

Seeking Easier Ways to Maintain Compliance?

Although we’ve helped explain appeals and grievances, CMS has dozens of other regulations that are important to keep up with to properly manage a facility. Uncover the latest industry insights you need to maintain compliance and deliver quality care with free access to the IntelyCare newsletter.