In this episode, Derrick Chavis, Manager of Reimbursement Services at BESLER Consulting reviews how the appeal process works for the Medicare Comprehensive Care for Joint Replacement (CJR) bundled payment program.
Michael Passanante: Hi, this is Mike Passanante. Welcome back. We are glad you’ve joined us for another episode of the Hospital Finance Podcast. And today, I am joined by Derek Chavis, who is a manager in our Reimbursement Services Team here at Besler Consulting.
And if you’re paying attention and you’re familiar with the Comprehensive Care for Joint Replacement Program, you know there are many new facets with this. And of course, one of the questions that people have is what is the appeals process? Is there an appeals process for this program? And Derek is going to help sort that out for us today.
So welcome back, Derek.
Derek: Thank you. It’s good to be here.
Michael: So first off, Derek, has CMS established an appeals process for CJR?
Derek: Yes, they have. CMS has established an appeals process, but that process is very similar to that being used currently in other programs. For example, the cost reporting process.
Michael: So specific to CJR, can you break down what that CMS appeals process looks like?
Derek: Sure. Again, the process is very similar to the process that we’re all currently familiar with. There are two levels of appeal. The first level of appeal is an appeal of potential error, and requires the participant hospital to notify CMS of an error within 45 days, or the calculation in question will be deemed final.
CMS will respond within 30 days in writing, and either agree, disagree or provide notice of extension. Only the participant hospital can use this process.
In the second level of appeal, we are appealing a dispute resolution process. This involves a request for reconsideration of an adverse determination to the first level of appeal. It must include a detailed explanation of the basis for the dispute, and the days of CMS’ response to the participant hospital’s notice of calculation error.
CMS will notify the participant hospital of receipt, and next steps, and the review by CMS will occur within 30 days of that notice. A written determination will be issued by CMS within 30 days, and will be final and binding.
Michael: Derek, can you help us understand what a hospital is able to appeal in this appeals process?
Derek: Sure. A hospital may appeal errors in payment, or reconciliation. Some examples include calculation of reconciliation payments or repayments, calculation of NPRA, calculation of percentage of quality performance, or determinations of successful reporting of voluntary outcomes and risk data.
Michael: Let’s flip that around. What can’t a hospital appeal?
Derek: Good question. Some of the things that a facility may not be able to appeal would include selection of CJR model for testing by CMS, selection of a hospital to participate in the CJR model, details around the CJR model implementation, and termination of design modification around the CJR model, including expansion of its duration and/or scope.
Michael: Excellent. Thanks for breaking that down for us today, Derek. I think that helps clarify what this appeals process looks like for hospitals that are in the CJR program currently or may have to participate at some point in the future.
Derek: Thank you.