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Formal Telephone Discussion Demonstration Updates from C2C

In 2015 CMS authorized the Formal Telephone Discussion Demonstration. C2C mailed out the first scheduling letter in January 2016 and the first discussion was held in February of 2016. At that time, the demo was limited to oxygen and glucose diabetic testing supplies only, and it was only in jurisdiction C and D. As of October 31, 2016, the demo has now been expanded to all DME appeal types with the exception to claims or suppliers that are already subject to another CMS initiative. For example, the settlement conference facilitation, or serial claims initiative, or prior authorization for power mobility devices, the demonstration is still only in Jurisdiction C and D.

The purpose of the Formal Telephone Discussion Demonstration is to conduct formal recorded discussions with suppliers prior to C2C's reconsideration decision. Participation in the demonstration gives selected suppliers the opportunity to discuss their appeal or case with the decision maker. The supplier has the opportunity to provide verbal testimony, and provide additional documentation that could assist in reaching a favorable determination.

As a result of the demonstration the expected outcome is improved proper claim submission to the DME MAC from suppliers who are participating in the phone discussion demonstration.

There is also a reopening component of the demonstration that allows potential cases to be remanded back to the QIC from the ALJ level.

Benefits to participating in the Formal telephone discussion are as follows:

The supplier gets to provide any verbal testimony during the call
The supplier has 14 days after the call is held to provide any missing or critical documentation that is needed to support a favorable decision
During the Phone discussion, the supplier will receive feedback and education on CMS policies and requirements.

Benefits to participating in the Reopening process are as follows:

Supplier will receive claim payment sooner than at the ALJ
Ability to submit documents on cases pending at the ALJ
Telephone Discussion on reopening case as necessary

The Formal Telephone Discussion Demonstration process is as follows:

First C2C, the Qualified Independent Contractor or QIC, receives the initial appeal request. Then the QIC determines if the appeal meets the criteria for a telephone discussion (Jurisdiction C or D) and it is not in any other CMS initiative.

Next C2C notifies the supplier of the scheduled discussion date by a mailed notification letter which includes a contact information form to be faxed back to C2C indicating election to participate. If C2C does not receive the contact information sheet within 14 days of the date of the letter, they will assume you do not wish to participate and the appeal will be handled through the standard reconsideration process.

The notification letter looks like all other C2C correspondence, the subject line will state Formal Telephone Discussion, Notification and Scheduling. Fax back the fourth page within 14 calendar days from the date of the letter to indicate election to participate.

At the scheduled date and time that the formal telephone discussion is conducted, the supplier will have the opportunity to provide verbal testimony, submit any missing or critical documentation needed to further support a favorable decision, and receive feedback and/or education on CMS policies and requirements. The formal telephone discussion will be recorded and a copy of the recording will be placed in the administrative case file.

If during the call additional documentation is required to cure claim payment the supplier will be notified in writing and will have 14 days from the formal telephone discussion to submit the additional documentation.

After the Formal Telephone Discussion, C2C will review the verbal testimony and written documentation in the case, apply Medicare policies, and make a decision on the case. The formal telephone discussions offered under this demonstration have a modified timeframe for the issuance of the decision. Instead of the standard 60 days, CMS has extended the time frame to issue a decision under this demonstration to 120 days. If a supplier is dissatisfied with the C2C decision, the supplier will continue to have appeal rights to the Administrative Law Judge.

The 120 days begins from the date that C2C receives the initial appeal. This 120-day timeframe is allotted to account for the scheduling of the formal telephone discussion, time to remit the contact information sheet, hold the discussion, and allow for the 14 days that are given to suppliers to submit additional documentation if needed.

Under the Demonstration, C2C will also conduct reopenings of claims that are similar to those selected as part of the formal telephone discussion. The criteria for reopenings are unfavorable reconsideration decisions dated on, or after, January 1, 2013, and that are from the respective DME MAC Jurisdictions C (CGS) and D (Noridian). Reopenings will include claims previously closed by the QIC, and/or currently pending but not yet scheduled with the ALJ.

C2C will be working closely with the Office of Medicare Hearings and Appeals and the suppliers, as part of the discussion process, to determine if these claims can be reopened by the QIC. They must have a high probability that, upon the submission of the additional requested documentation, the case may warrant a reopening and result in a fully favorable decision.

The Reopening process is as follows:

The supplier will be notified in writing of cases included in the reopening process along with the missing or insufficient documentation required to allow payment.
Upon receipt of requested documentation, C2C shall confirm the documents support a favorable decision. If a favorable decision cannot be rendered, the supplier will be notified in writing.
Notify ALJ of claims that can now be resolved favorably via a C2C reopening, and request cases to be remanded (applicable only to appeals pending at ALJ).
Upon receipt of the ALJ remand, as applicable, reopen and render favorable decision.

The Reopening Process Request Form is located on C2C website under the forms link. The form should be completed to request a reopening of a pending ALJ appeal that was denied by the QIC between January 1, 2013 to present. Fax the request to the contact number found under the address portion of the form.

C2C experienced significant delays in responses from suppliers regarding additional documentation request letters, and due to this delay, C2C has changed the time frame to 30 days that the supplier has to remit the requested documentation versus the previous 14 days. C2C sends a letter to the supplier reminding them and outlining the cases that were pending and have a documentation request. C2C is conducting follow-up calls to review the new timeframe and remind suppliers of the cases pending that have documentation requests.

C2C provided an overview of the demonstration for 2017 thus far. From January to July of this year C2C mailed out over 19 thousand scheduling letters and held approximately 17 thousand formal telephone discussions, which equates to about an 83% participation rate in discussions.

For the reopening component of the Phone demonstration for far for 2017, C2C have worked with the ALJ on either reopening or having withdrawn from the ALJ approximately 39 thousand claims.

C2C shared lessons learned for for the demonstration thus far. C2C found that it is imperative that the contact information form be returned in a timely manner, and to the correct location.

Education and outreach has to start as soon as possible with the expansion. C2C indicated that they didn't begin education and outreach until March of 2016, which didn't give suppliers enough time to become familiar with the process and aware of what the demonstration was. When the expansion took place C2C learned that they would need to start educating a lot sooner.

C2C found that establishing a point of contact with the suppliers made for a smoother process.

Lifting the five-claim limit per NPI, that was initially on the demonstration, allowed C2C the ability to send more scheduling letters to suppliers who previously exceeded the cap.

For the Reopening process when a business has changed locations sometimes this can cause a delay or prevent the supplier from receiving the correspondence that C2C is sending. C2C asks that if a supplier has changed locations since January of 2013, to let C2C know so that they can ensure Reopening correspondence is going to the correct location.

Lastly the staffing allocations and staffing assignments for some suppliers has been an issue. If there is only one individual assigned to conducting the phone discussions and locating the documents for the reopenings, for suppliers who are submitting large volumes of reconsiderations or have a large number of reopenings that qualify for the demo this can be a daunting task. C2C has been able to meet with executive level administration and communicate these needs to them.

C2C has designated Emily Barnes to assist suppliers with any information related to the demonstration. Her contact information is Emily.Barnes@c2cinc.com. Also, the C2C website that has more information about the Phone Discussion Demonstration at www.c2cinc.com. You can find information about the phone discussion demonstration, the reopening process, frequently asked questions, forms as well as our quarterly newsletter. You can also submit your email address to be added to the C2C list serve if you are interested. If suppliers have any feedback regarding the Formal Telephone Discussion email dmepdfeedback@c2cinc.com. This feedback is shared with CMS.

Questions Received During the ACT meeting

Click on a question to expand or Show All / Close All

I know C2C is working with CGS for Jurisdiction C. Will you be expanding this to Jurisdiction B?
- The demo is limited to Jurisdiction C and D for the Formal Telephone Discussion. Jurisdictions A and B are a control group. With these Jurisdictions not participating it provides CMS with data to ensure the demonstration is working.
  
  Published: 09.19.17
We have a claim out through ALJ, and we were able to come up with additional documentation to send to the ALJ. Will it come back to C2C or are we supposed to file it to C2C? How does that process work? Will it be Reopened?
- C2C does not have access to the additional documentation that you send to the ALJ after it was denied at the Reconsideration level. The documentation is needed for review. If C2C has not already asked for it, then you can fill out the Reopening Request Form found on C2C's website and fax that in, along with additional documentation that you have obtained since it was denied at the Reconsideration level.
  
  C2C will review the case, identify if there is anything additional that is needed and if so we will notify you by letter requesting additional documentation. You will have 30 days from the date of the letter to send back additional documentation. If we do receive the requested documentation to cure claim payment, then at that point, we remand the case or pull the case back from the ALJ and reopen it and begin the reopening process here at our level.
  
  If for some reason the documentation is not received or does not meet policy to cure claim payment, you do not lose your place in line at the ALJ. It's as if we have not even touched the appeal at that point.
  
  Published: 09.19.17
We have a claim that we sent to ALJ, we're waiting for our hearing. We do not have any additional documentation to submit. Should we still pursue the C2C reopening?
- Absolutely. The only qualifier for the demonstration for the reopening process is that it had to be denied by C2C between January 1, 2013 to present, it must be Jurisdictions C and D, and it has to have the ALJ appeal date, unless it is within 60 days of the reconsideration denial. If it meets that criteria and a request for additional documentation has not been sent, you can fax the form in and we will begin the process.
  
  Published: 09.19.17
How are the files selected when you're going through the process of reviewing accounts that could potentially be pushed forward and possibly paid? When C2C selects an account, is there a particular criteria that you're looking at? Are you looking at based on the type of product that the DME provider is supplying and maybe the highest number of denial reasons that you receive, whether it's for medical necessity or one of the requirements? We're trying to understand how do you initially select, randomly select an account to be reviewed at another level or at this particular level.
- C2C reviews first to see if the claim meets the criteria of Jurisdiction and time frame, after January 1, 2013 to present. Then we review if the original decision was clear, and if it's something we could potentially make a favorable decision on with talking to the supplier and/or requesting additional documentation.
  
  We are not able to do a formal phone discussion on every case, so even if your request fits that criteria, there's only so many that we can complete in a week, a month, and a year. So, it still may not get pulled for review. But, we are trying to give everybody an opportunity.
  
  Published: 09.19.17
If we requested an ALJ reopening and because of time constraints or whatever reasons, it doesn't get reviewed, will it remain in the queue for ALJ? Will it stay in line at the ALJ or will we lose our place in line?
- If you have faxed in a potential reopening request to us, and it gets to ALJ, and they schedule a hearing before we do anything with it, you will not lose your place in line at the ALJ.
  
  Published: 09.19.17
I have a Reopening that was denied and I have a favorable decision for another date. Can I resubmit for another reopening on the one date that denied now that I have a favorable decision?
- A11. If this has happened, please send the case numbers to Emily.Barnes@C2CInc.com and we will research this further.
  
  Published: 09.19.17
I received a hearing notice for several claims, and two of the claims on that hearing notice were in the process of reopening with C2C. I had received letters that they were being reopened and I contacted C2C and was told I should receive a decision prior to the hearing date. I contacted OMAHA and was told I may need to request a dismissal of the claims that were reopened. I did receive the decision on one, and it was favorable. I haven't received a decision on the other one, but it just confused me why ALJ didn't already know about it?
- When we send the ALJ the notice that we're going to work with you on potentially reopening at our level, they're supposed to put the claim in a holding pattern and not schedule it for a hearing. It has happened in the past on occasion. Please contact Emily.Barnes@C2CInc.com with the case numbers and we will review if they were reopened. If they have we will reach to OMAHA but either way we will get back to you prior to the hearing.
  
  Published: 09.19.17
We have moved. How should I notify C2C?
- Please email that information to Emily.Barnes@C2CInc.com and we will update our records. We will forward all correspondence to the new address.
  
  Published: 09.19.17
As far as doing the reopening, you said I can initiate this if I have something that was denied by C2C and has gone to the ALJ, correct? Where are, these forms located?
- Go to C2C website at https://www.c2cinc.com/. At the top of the webpage, select Phone Demonstration, on the left-hand side select forms, select the Reopenings Process Supporting Documentation Cover Letter for PD Reopening Use Only form. Complete the form and fax this to us for review with any supporting documentation.
  
  Published: 09.19.17
We received a request for additional documentation on a claim that was at ALJ that you guys were going to reopen. We submitted that documentation. What is the timeframe for you guys to process that and make a decision on those?
- Once we receive that documentation, our nurses and our medical staff review that documentation to make sure it is in fact the documentation that we need to cure claim payment. Then we begin a process with OMAHA to request the remand from them. We are at their mercy at that point waiting for them to get the remand back to us. Then, once we receive that remand, it goes through the process of us actually reopening it, issuing that decision letter, sending the effectuations to the MAC.
  
  It's hard to put an actual amount of time or date or certain number on that, but if there are any that you would like to follow up with me on, you can send an email to Emily.Barnes@C2CInc.com and an update will be provided.
  
  Published: 09.19.17
I have several claims that we've submitted from 2014 and ‘15 that are at the ALJ level. We were advised of the two-year backlog. Now, is that still in effect? Is the backlog still in effect for those appeals?
- Yes, and if you've heard two years, that's great. If the appeals at ALJ have not received a hearing date yet, then they would be eligible for the demonstration and you can move forward with requesting those from C2C.
  
  Published: 09.19.17
Is there a backlog on the demonstration as well?
- No, we have not experienced any type of backlog or anything like that here at our level.
  
  Published: 09.19.17
When we submit a request for the reopening, will this push the appeal back from the ALJ level?
- We place a hold on the appeal. We let the ALJ know or we let OMAHA know that we are potentially working with this case. Then, if we receive the documentation to meet policy, we request that remand from them, it's pulling it off of their plate or off of their caseload, and we are taking care of it at our level.
  
  Published: 09.19.17
Once it is remanded from ALJ, C2C can make the determination whether it's denied or favorable?
- It will only be reopened and pulled back from OMAHA if it will be a favorable decision. We will not pull anything back if it's going to be unfavorable. This is the reason why we do not request a remand from the ALJ until we review the documentation to ensure the documentation will cure claim payment. If the documentation will cure claim payment, that's when we're going to pull it back and reopen it. If it's not the documentation that we need, then we let OMAHA know we are not going to work with this case and for it to resume its place in line at the ALJ.
  
  Published: 09.19.17
Who should we contact to reschedule a telephone discussion?
- Within the scheduling letter there is a contact number, this number is to our scheduling department and they will reschedule the discussion with you.
  
  Published: 09.19.17
Will there be an option to fax or upload documents in the near future or is everything required to be mailed?
- Faxing is acceptable now, and that's our preferred method because it is quicker. The fax number is on all our documentation that we send out. Anything that's requesting a remittance is also going to have the fax number on it. We are working towards a portal in the future so documentation can be uploaded securely but at this time we do not have a portal.
  
  Published: 09.19.17
We are submitting an initial reconsideration request following an unfavorable redetermination request, can we request a telephone discussion at this time on the form? If so, we have no new documentation to include as we believe the documentation necessary was sent initially. Can we request a telephone discussion?
- Yes, submit the request form with the reconsideration to hold a formal telephone discussion, and then when we see that, we'll look at it and see if it qualifies for the demonstration. If it does qualify, a scheduling letter will be sent to the supplier.
  
  Published: 09.19.17
Is the faxing only for the formal discussion or for reopenings?
- Faxing is for both formal discussion and reopenings.
  
  Published: 09.19.17
Do we just write the request on the reconsideration form for a phone discussion? There's not a box to check that we want that formal discussion.
- Yes, that's correct. We can't modify the current request because that's a standard request that goes out for all the jurisdictions and not everyone's entitled to a phone discussion. A cover letter or just write on the reconsideration form itself that your requesting a formal discussion, something to get our attention so we can see it. Some suppliers have submitted it as a separate cover letter.
  
  Published: 09.19.17
We have a denied redetermination and then C2C denies, how can we request a formal telephone reopening? Then, what is the criteria? Because if we do that, we are cutting into our time to file the ALJ.
- If it's within the 60 days of C2C denying it, before the supplier has appealed to the ALJ. We always recommend that you still appeal to the ALJ so that if for some reason, we are unable to reopen the claim that you do not lose those appeal rights.
  
  Published: 09.19.17