Benefits Improvement and Protection Act of 2000  (BIPA)
Overview:

On July 1, 2005, the final rule of the Benefits Improvement and Protection Act (BIPA)
takes effect. A Medicare fee-for-service beneficiary (or authorized representative) is entitled to an expedited review process when he or she receives notice from, and disagrees with, his or her health care provider's plans to:

1. Terminate services provided to the individual and a physician certifies that failure to continue services is likely to place the beneficiary's health at significant risk; or
2. discharge the beneficiary from the provider of services.

Providers are defined as:

• Home Health Agencies (HHA)
• Skilled Nursing Facilities (SNF)
• Comprehensive Outpatient Rehabilitation Facilities (CORF)
• Hospice

The Centers for Medicare & Medicaid Services (CMS) has contracted with New Mexico's Quality Improvement Organization (QIO), the New Mexico Medical Review Association (NMMRA), to carry out the initial review.

NMMRA hosted trainings in June, 2005 to help your CORF, HHA, SNF or hospice comply with the requirements of BIPA. 

Expedited Review Process:

A beneficiary exercising his/her right to an expedited review must submit a request, in writing or by telephone, no later than noon of the calendar day following the receipt of the provider's notice of termination to the QIO in the state in which the beneficiary is receiving services. The beneficiary must be available to answer questions or to supply information that the QIO may request to conduct its review. QIOs will accept beneficiary requests for expedited review even if the beneficiary does not submit the request within the required timeframe, however, provisions related to beneficiary financial liability protection and the 72-hour turnaround timeframe for the QIO review do not apply.

Coverage of services continues until the date and time designated on the termination notice, unless the QIO reverses the provider's termination notice. Delays caused by provider failure to supply necessary information may make the provider liable for costs of any additional coverage, as determined by the QIO. The burden of proof rests with the provider in demonstrating that termination of coverage is the correct decision, either based on medical necessity or on other Medicare coverage policies. In order for the QIO to determine that the provider has met the burden of proof, providers should supply any and all information that a QIO requires to sustain the provider's termination decision.

Provider responsibilities:

1. Providers must deliver the Notice of Medicare Provider Non-Coverage (also called the Generic Notice) termination notice to beneficiaries no later than 2 days before the proposed end of covered services.
2. Upon learning that a beneficiary has requested an expedited determination, the provider, by close of business of the day of the QIO's notification, must send a detailed notice to the beneficiary containing the reasons why the services are no longer covered and applicable Medicare coverage rules or policy.
3. Providers may not bill a beneficiary who has requested an expedited determination for any disputed services until the expedited appeals process is complete (including an expedited reconsideration, if applicable).
4. Providers must provide the QIO with all information needed to make its expedited determination, including copies of the notice of termination and the detailed notice given to beneficiary, no later than by close of business of the day the QIO notifies the provider of the request for an expedited determination.
5. The provider must furnish, upon request, the beneficiary with a copy of, or access to, any documentation shared with the QIO. The provider may charge the beneficiary a reasonable amount to cover cost of copying and/or delivering the documentation.

Beneficiary Responsibilities

1. Beneficiary (or authorized representative) must acknowledge receipt of Generic Notice and contact the QIO within the specified timeframes if he/she wishes an expedited review

QIO (NMMRA'S) responsibilities

1. Immediately notify the provider of the disputed services that an expedited determination request has been made
2. Determine whether a valid termination notice was delivered;
3. Request and examine the medical record and if necessary, other pertinent records from the provider. If applicable, determine if a physician has certified that failure to continue provision of services places the beneficiary's health at risk;
4. Solicit the views of the provider and the beneficiary; and
5. Make a decision within 72 hours after receipt of the request for the QIO expedited review and notify the beneficiary, the beneficiary's physician and the provider of services of its decision.

The QIO's initial notification may be by telephone, followed by a written notice included the following information:

1. The rationale for the determination;
2. An explanation of the Medicare payment consequences of the determination and the date a beneficiary become fully liable for the services; and
3. Information about the beneficiary's right to a reconsideration of the QIO's determination, including how to request and reconsideration and the time frame for doing so

If the QIO does not receive the information needed to make a decision, it may make its determination based on the evidence at hand, or it may defer a decision until it receives the necessary information.

If a beneficiary is unsatisfied with a QIO determination, he/she may appeal to a Qualified Independent Contractor (QIC) for an expedited reconsideration of the QIO determination. The process for an expedited reconsideration by a QIC is similar to the QIO process for the initial determination. Beneficiaries must submit the request in writing or by telephone by no later than noon of the calendar day following the initial notification receipt of the QIO's determination. QICs must provide their reconsideration decision no later than 72 hours after receiving the appeal request and related medical records. If QICs are not in place at time of implementation, QIOs will perform the reconsideration function. A beneficiary may appeal the QIC decision to an Administrative Law Judge.

QIOs must provide QICs with all information needed to perform the expedited reconsideration no later than by close of business of the day that the QIC notifies the QIO of the request.

Beneficiary and Provider Education:

CMS will conduct beneficiary and provider outreach to make sure they are aware of their rights and/or obligations. The Agency will also review CMS surveying protocols and QIO review protocols to identify changes that may be needed to facilitate effective implementation, monitoring, and enforcement of the requirements of the final rule.

Major Change from the Proposed Rule

Use of the "Generic Notice"

The proposed rule used the Advanced Beneficiary Notice (ABN) as the vehicle for notifying beneficiaries of the right to an expedited determination. The final rule, however, includes the establishment of a new, standardized notice for beneficiary notification of discharge or service termination, called the Notice of Medicare Provider Non-Coverage, or Generic Notice. If a beneficiary chooses to pursue an expedited determination, a second, more detailed notice will be furnished which explains how Medicare coverage rules apply in individual situations, address liability issues, and facilitate the expedited review process by providing the patient-specific information needed by the beneficiary and the QIO.

The standardized termination notice must include the following information:

1. The date that coverage of services ends;
2. The date that the beneficiary's financial liability for continued services begins; A description of the beneficiary's right to an expedited determination under section 405.1202, including information about how to request an expedited determination and about a beneficiary's right to submit evidence showing that services must continue;
3. A beneficiary's right to receive the detailed information specified under section 405.1202(f); and
4. Any other information required by CMS.

The notice is valid when the beneficiary (or authorized representative) signs and dates the notice, is delivered within the timeframe required, and contains all the required elements noted above. A beneficiary may refuse to sign the notice. In this case, the provider may annotate the notice to indicate the refusal. The date of refusal is considered the date of the receipt of the notice. A provider is financially liable for failure to deliver a valid notice for continued services until two days after the beneficiary receives a valid notice or until service termination date specified on the notice, whichever is later.

Other Provisions

Changes to Expedited Reviews of Inpatient Hospital Discharges

Requires QICs to perform reconsiderations of unfavorable QIO decisions. Current practice allows for QIOs to conduct the reconsideration. If QICs are not operational by the time the regulation is effective then QIOs will continue the reconsiderations.

Hospital requests for QIO review (Section 405.1208 of the final regulations)

This section outlines longstanding rules concerning the right of a hospital to request and expedited QIO review. A hospital may request QIO review if it believes the beneficiary does not need further inpatient care but is unable to obtain physician agreement.

Cost estimate

CMS estimates first year costs, including training and start costs for QIOs, to the Medicare Trust Fund of about $32 million to carry out this function.

For Additional BIPA Provider Information:

Click here for a BIPA article recently published in Medlearn Matters, the Medicare Providers Newsletter.