Department of Health and Human Services DEPARTMENTAL APPEALS BOARD Medicare Appeals Council | |
IN THE CASE OF | Claim For |
M. F.
(Appellant) |
Hospital Insurance Benefits (Part A)
|
M.F. (Beneficiary) |
*** (HICN) |
Cahaba GBA
(Carrier) |
|
ORDER OF REMAND | |
The Administrative Law Judge (ALJ) issued an order of dismissal dated
December 24, 2003. The appellant has asked the Medicare Appeals Council
to review this action. The Council grants the request for review because the action, findings or conclusions of the ALJ are not supported by substantial evidence, and there is an error of law. 20 C.F.R. �� 404.967 and 404.970, incorporated by reference in 42 C.F.R. � 405.724. This case concerns home health services rendered to the beneficiary from
November 11, 2002 and January 8, 2003. The intermediary denied coverage
for a skilled nursing visit on December 9, 2002, and the beneficiary,
represented by the home health agency, appealed. The ALJ dismissed the
case because the amount in controversy did not exceed $100. The ALJ calculated
that the amount in controversy for the one denied visit was $92.48, which
was "the amount for each of the three visits reimbursed by Medicare" in
the period at issue. After reviewing the record and the request for review, the Council finds
that the ALJ erred in calculating the amount in controversy. According
to section 1869 of the Social Security Act, the required amount in controversy
for appeals to an Administrative Law Judge in a Medicare Part A case is
$100. Medicare regulations at 42 C.F.R. � 405.740(a)(1) define the amount
in controversy as "the actual amount charged the individual for the
items and services in question, less any amount for which payment
has been made by the intermediary and less any deductible and coinsurance
amounts applicable in the particular case" (emphasis added). In this case,
the billed amount for the single denied visit on December 9, 2002 was
$160. There are no deductible and coinsurance amounts. Therefore, the
amount in controversy is $160. Exh. 5. Accordingly, the appellant meets
the amount in controversy requirement for a hearing. The Council hereby
vacates the order of dismissal and remands this case to an ALJ for further
proceedings. At the hearing on November 12, 2003, and in the request for review, the
home health agency argued that, because it was being paid under Medicare's
prospective payment system, the amount in controversy was actually the
difference between the amount it would have been reimbursed for the period
had Medicare covered five visits (the episode payment) and the amount
it was reimbursed for four visits (a per-visit payment) - a difference
of more than $700. We acknowledge that, under the prospective payment
system, providers are reimbursed for each 60-day episode at a per-episode
rate, unless they bill four or less visits during that episode. In that
case, they receive a lower, per-visit payment, referred to as the low
utilization payment adjustment (LUPA). See 42 C.F.R. �� 484.205(a)(1),
484.230. However, we note that there is inconsistent evidence as to whether
the agency actually billed for four or five visits originally. Exh. 5.
On remand, the ALJ shall determine the number of visits that were rendered,
correctly billed, and reimbursed during the period at issue. The ALJ may take further action not inconsistent with this order.
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JUDGES | |
Clausen J. Krzywicki Thomas E. Herrmann |
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