Learn About Appeals at Acentra Health

As a contractor for Medicare, Acentra Health serves as the Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO. While Acentra Health provides BFCC-QIO services in 29 states, the general information is relevant to everyone who has Medicare (including Medicare Advantage) and everyone who works with people who have Medicare.  

This episode is a conversation with our guests, Rose Hartnett, RN, MS, Operations Director, and Trena Dodson, LPN, Appeals Manager, for Acentra Health. In this podcast, our guests will share information about our hospital discharge and skilled service termination appeals as well as our new observation appeals. 

For more information about Acentra Health BFCC-QIO, please visit www.acentraqio.com. 

KEY TOPICS 

00:24: Overview, introduction of guests, Rose Hartnett and Trena Dodson 

02:40: What are the different types of appeals? 

07:43: Explanation of the appeals process 

10:43: Examples of why appeals are filed 

12:03: What do physician reviewers look for while reviewing an appeal? 

13:54: Final thoughts  

SUBSCRIBE

Subscribe to our newsletters: Case Review Connections, On the Healthcare Front at www.acentraqio.com.

RESOURCES 

BFCC-QIO Information for stakeholders: www.acentraqio.com/partners 

BFCC-QIO Information for people who have Medicare: www.acentraqio.com/bene 

BFCC-QIO Appeal Information - https://acentraqio.com/bene/appeal.aspx

BFCC-QIO's Case Status Tool (check appeal status) -  https://acentraqio.com/casestatus/

Music: Motivational Upbeat Corporate by RinkevichMusic  

https://soundcloud.com/rinkevichmusic 

https://protunes.net/  

Video Link: https://bit.ly/3NNqGTs 

Transcript

Welcome to Aging Health Matters, a podcast from Acentra Health, a Beneficiary and Family Centered Care Quality Improvement Organization. We plan to cover healthcare topics for the Medicare population. Information in today's show may help you or someone you know in their healthcare journey. Thanks for joining us. Now let's get started.    

Hello everyone. My name is Scott Fortin, and I'll be your host today for another edition of our podcast, Aging Health Matters. Acentra Health is the Beneficiary and Family Centered Care Quality Improvement Organization for 29 states. We help people with Medicare who have concerns about their health care. We can help you appeal if you're leaving the hospital too soon, which is the topic for today, or if skilled care, like physical therapy, is ending early. We also offer Immediate Advocacy services to help fix problems quickly with medical care or with services. More information is available in the Show Notes and on our website at acentraqio.com.  

I'm very excited today because our topic is appeals, and I'm very excited because I have two of my colleagues with me today. Normally, as you know, if you've been a fan of our podcasts, we will have some of our other partners, external partners, with us. But today we have two folks that work with people on appeals each and every day, day in and day out. So that is Rose Hartnett and Trena Dodson. Welcome ladies to the podcast. 

Thank you. Nice to be here. 

Thank you, Scott. 

Ladies, could you tell the audience a little bit about yourself as far as what you do for Acentra Health?  

Absolutely. So my name is Rose Hartnett. I am the Operations Director at Acentra Health. I do oversee the appeals department and that includes physicians, nurses, and our call center representatives. I am a nurse, and I've been doing QIO work for nine years now. 

Hello everyone. Thank you for having me. My name is Trena Dodson, and I am one of the appeals managers. I oversee the day-to-day functions of the appeals process as the appeals come into our team. I myself am a nurse as well, and I've been with the company now doing QIO work for nine and a half years. 

Wow, that's great. So a couple of veterans here of almost 10 years of this type of work. Really appreciate both of you making some time to talk to our audience today. So a little bit about the appeal process. As you go into a facility and get care as a Medicare beneficiary, you may encounter situations where you would like someone to take a look at your situation. And that's where an appeal comes in. And there are several different settings. So when you contact us, when you find us via the website or through the notice that you receive from your healthcare provider, and you are put in contact with Acentra Health, and you call that number, you'll reach one of the folks that work with these two nice ladies here, and from there, they will take you through the appeal process.  

Now to clarify for our audience a little bit. Rose or Trena, whichever one of you'd like to take this. I know that there's different types of appeals based upon the setting that someone's been in, whether it's been a hospital or a skilled nursing facility, home health, hospice, whatever that is. Could you maybe explain a little bit of the difference? I think there's like three or four different types of appeals to kind of go through. 

Yes. Thank you, Scott. This is Trena. So we do have several different types of appeals. First, we have the acute appeal. Those types of appeals are filed when you're in a hospital inpatient setting, and you're ready to be discharged to a lower level of care. The hospital will issue you a notice letting you know that you are going to be discharged, but that notice gives you the right to file your appeal. And it also gives you the instructions on how to file the appeal. Then we have the long-term acute care. It's not quite the actual hospital setting.  

However, it is still an acute level of care, but it's just that you can stay there a little bit longer. That type of facility also will issue a notice explaining that you're being discharged and giving you the appeal rights. And then there is the acute rehabilitation. That one is for someone who needs additional therapy but also has an acute type of diagnosis that still needs to be addressed by a physician. So those are the three types of acute hospital appeals that we do.  

There are also other types of hospital appeals that we will process. There is a type of appeal where they're not quite ready for acute inpatient care. They may be in observation status, and they may issue them the Hospital Issued Notice of Non-coverage. That type of appeal we call a HINN appeal. That also occurs in the hospital, and they can be discharged from that type of setting, so they have the right to file an appeal to see if they are able to be admitted to inpatient.  

And then we have the new type of hospital appeal, which went into effect February 14, 2025, which is the observation appeal, and that observation appeal is for a beneficiary who was admitted to inpatient, and then their status was changed back to observation while they were in the hospital. Those are for Medicare beneficiaries who do not have a Medicare health plan. But they will be issued a notice as well. And that notice gives them their rights to file an appeal.  

We also have post-acute where they're not in a hospital setting, or they don't require that acute level of care. And those types of appeals. they may be in a skilled nursing facility receiving rehabilitation or having different non-acute issues addressed. And with a skilled nursing facility, they also will issue the Notice of Medicare Non-coverage, which tells them when their last covered day is, and they're being discharged. That gives them their appeal rights. They call us and file an appeal.  

There's also home health. That is another post-acute setting where they have appeal rights, and then there's outpatient rehab, where you could be at home but go to a facility to receive your occupational or physical therapy. So we process those appeals, and for all of those appeals, they will issue that Medicare Notice of Non-coverage. And they have the right to appeal those services as well.  

Then we have the hospice services. If you're receiving hospice care, you would be issued that notice when the hospice agency determines that you no longer require that level of care, and you have the right to file that appeal. 

Wonderful. Thank you. And so to be clear, for our audience sake, when we refer to the Notice of Medicare Non-coverage, that is something that is generally given to the Medicare recipient and/or their family prior to discharge, and that is something that will contain our information on it for those that are wondering.  

So that is how people generally do get a hold of us. Now once that process is set in motion, if you will, Rose and Trena, once we've had someone contact us via the phone number that they have found on that notice or the website or seeing it somewhere else from another document that we've put out there, the appeal process starts from there and correct me if I'm wrong with a conversation with one of our staff and from there, who works through the medical records because the appeal is based upon the medical records, am I correct? 

That's correct, Scott. So when Medicare beneficiaries are issued the notice, if they're in the hospital, the notice they get is the Important Message. If they're in a post-acute setting, it's called the Notice of Medicare Non-coverage. Once they receive that, they can call Acentra Health, and our customer service representatives will take the information about their stay and why they feel that they want to appeal, why they're not ready to either be discharged or move to a lower level of care.  

So once that happens, we request their medical records from the provider, and our physician's decision is based on what they find in the medical record. We also do take into account whatever statement the beneficiary or the family has given us as to why they are appealing their case. So once we receive the medical records from the healthcare provider, we have nurses that review the case, and then they send it on to a physician for a final review and determination.  

When we get that back, we have either a nurse or a call center representative call the beneficiary or their family with the decision. We also let the provider know and the health plan if they have a Medicare Advantage plan. And that's basically the process. If we agree with the Notice of coverage, meaning that they are ready to either be discharged or moved to a lower level of care, they do have the right to file a reconsideration appeal. 

And if they do that, we will use the same records but send it to a different physician to review and see if they agree with that original decision, 
or they want to overturn that decision. The important part there is that liability does start when we have given our initial decision. If we agree that the patient is ready for discharge, that liability date remains the same during the reconsideration process. If the reconsideration is overturned, that liability date will not be used, and the facility would have to issue a new notice to the beneficiary. 

That's great. So thank you. You explained the levels and some of those things. So can you give me some examples of some of the reasons that you all have seen. I know you've seen probably a ton of reasons that people filed appeals, but can you give us some of the most basic ones or the ones that you see most often, the reasoning for people filing an appeal with Acentra Health? 

I think the main reason is usually the patients don't agree that they're ready to move to that next level of care, either in a post-acute situation where someone's in a skilled nursing facility, which is the majority of the appeals that we receive. It's usually because the beneficiary is not able to return to the level that they originally were in before admission. And while that's not always possible, the goals are usually pretty close to that. 

If patients feel that they haven't met the goals that were made for them in the beginning of their stay, that's usually why they want to appeal, and that's why we review the medical record because we want to see what your original evaluation was and what the goals were, what they thought that the beneficiary would be able to reach, to see if that really does match what the discharge notice is telling us. 

Thanks for that. When I look at this for example, what are peer reviewers looking for when they're making a determination? From a personal standpoint, I've had family members that have been in the hospital that may get information from the hospital that's getting ready to send them home maybe faster than my family member was ready to. In a case like that, if we were to do an appeal, that's something I think around how capable the person feels to be in their home or if they were stable as far as like, let's say their numbers or something like that, is that kind of what the peer reviewers are looking for when they're reviewing a file? 

It is. What the physicians are looking for is is it medically necessary for the beneficiary to be in the setting that they're in, or are they ready to move to a lower level of care? And that's what Medicare is looking for. They will cover care that's medically necessary in the appropriate setting. If you're being discharged from the hospital, the hospital is required to have that next level set up for you whether they're sending you to a skilled nursing facility or home with home health care. That is something that we look for, to make sure that they have actually done that work and make sure that you are ready for the next level of care and that that is ready for you. So that is something that our physicians look at. 

And may I add that it is the provider's responsibility, through the medical records, to demonstrate that the beneficiary discharge into that lower level of care is appropriate. To piggyback off of what Rose is saying, that's what the physicians are looking for in the medical records, to make sure that their discharge to a lower level of care is appropriate. 

Got it. So kind of in closing to some of this great information you've given us today, I'm going to look at your 18 years of combined experience in doing this work. What sort of suggestions would you give to the audience that has had an experience like this or feels that they need to go through this process? Are there suggestions you would make to them about the approach or when to call or anything of that type of thing? 

For the beneficiaries, if they wish to file an appeal, in order to limit their liability if the decision is upheld, it is best for them to call to file their appeal when they receive the notice. There are deadlines stated on each type of notice. So as Rose stated, for the acute type of appeals, you will receive the Important Message. Those notices will inform you that the appeal must be called in by midnight the day that you received it. And for the post-acute appeals, they have to be filed by 12 noon the day after you receive it.  

So it's important that you are reading those notices, either the beneficiary or their representative, that you understand what you're reading. Ask questions. You're more than welcome to call us and ask questions regarding the appeals process. So please don't hesitate to ever reach out and if you don't have an understanding of how this process works. But I think that's most important for the beneficiary and the representative. And for the providers, it is most important that they submit those medical records timely, and when you receive the medical records request via fax, it does indicate when those medical records need to be submitted. So please make sure you're submitting those timely, so that the appeal can be processed. 

Absolutely, and that's great information. Thanks Trena for kind of tying that together for us and a shameless plug for our website. Both of these ladies have worked with us to get information out on our website that is detailed beyond what we could provide to you on this podcast as well as us having the ability for those medical records to be sent through a portion of the website by the providers. So we do have that capability. So I would again, as I mentioned at the beginning of the podcast, urge you to go to acentraqio.com for more information about the appeals process and about the medical records and how those can be sent by the providers on behalf of the beneficiaries. So ladies, I really appreciate your time today. Any further thoughts for our audience before we go? 

No, I just want to echo what Trena said. You can always call us and speak to a nurse if you have any questions, whether it's clinical or about your liability or just about the appeal process, just call and ask to speak with the nurse, and we will have a nurse give you a call back. 

Sounds great. Thanks Rose for the reminder on that. And as far as our website is concerned, just so everyone's aware, if you have not been to acentraqio.com, it does show you state-by-state how to reach us. It gives you the phone number of how to call us as well as the hours that our call center is open. So all of that information is available for you there. It will also be provided to you in the Show Notes for this podcast. 

So again, I just wanted to say thanks Rose and Trena for your time, and everybody, if you have not caught yourself up on previous podcasts, I would urge you to do that because we've covered some other topics that would be relevant to this group as well. And again, go to the website, acentraqio.com, check out our YouTube channel and just educate yourself on your rights. And if there's anything we can do to help you as Rose and Trena said, please don't hesitate to reach out to us. So for today, I bid you goodbye and thank you for your time in paying attention to our podcast. Have a great day everyone. 

Thanks Scott. 

Thank you.