BREAKING: MAC Advises Providers to Appeal Denials

“Urgent” memo marks obvious disagreement among contractors.

In what can only be described as highly unusual, a Medicare Administrative Contractor (MAC) has advised home health providers who have had claims audited and denied by the Comprehensive Error Rate Testing (CERT) contractor to appeal those denials. The announcement was made today by Ronald Hirsch, MD, during a live broadcast of Monitor Mondays. 

According to Hirsch, of R1 RCM Inc, starting in January 2018, the Medicare Conditions of Payment required home care plans of care to include “information related to any advanced directives.” For many home health agencies, a “do not resuscitate” or a physician order for life-sustaining treatment (POLST) or similar document was considered, and sometimes included in the plan of care, but in some instances there was no information about the presence or absence of other advance directive documents, such as a medical power of attorney or living will. For others, information related to such documents was obtained, but not documented in the plan of care. In either instance, the lack of the information led to a CERT denial, according to Hirsch.

“In response to these denials, the National Association for Home Care & Hospice (NAHC) released a memo on Jan. 9, 2019 to its members, and their recommendations were summarized in a Jan. 10, 2019 article published in Home Care magazine,” Hirsch explained. “Five days later, CGS, the Home Health MAC for Jurisdiction 15, released a notice (titled) ‘Urgent Information for Home Health Providers: Advanced Directives.’”

In this memo, CGS reiterated the requirement for information related to the advance directives in the plan of care, but then went on to note that “providers are encouraged to appeal these types of denials from the Comprehensive Error Rate Testing (CERT) program/contractor.”

“When a provider appeals a CERT denial, the redetermination is handled by the MAC,” Hirsch said. “The fact that CGS is advising providers, in an urgent memo, no less, to appeal these CERT denials for lack of advance directive information seems to mean that they feel the denial of these by the CERT contractor was improper, and that CGS will reverse the denial.”

According to Hirsch, it is highly unusual to see one Centers for Medicare & Medicaid Services (CMS) contractor directly and publicly contradict the findings of another. The memo also states that CGS is in communication with CMS about this issue, suggesting there will be more to come.

“This apparent disagreement between contractors comes on the heels of last week’s report that CMS has instructed the MACs not to recoup payment on short-stay inpatient admissions denied by the QIOs (Quality Improvement Organizations) and the withdrawal by CMS of MedLearn Matters 10600, related to total knee arthroplasty status determinations,” Hirsch said.

RACmonitor and Monitor Mondays will continue to report on these issues. 


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