C2C Innovation Solutions Begins Pilot Program that Gives Suppliers a Bigger Voice in Defending Claims

Posted on in Billing/Reimbursement

At the Medtrade Spring Jurisdiction D council meeting, C2C Innovation Solutions introduced a two-phase demonstration that will give select suppliers an enhanced opportunity to provide critical feedback and increased analysis of denied claims. The initial process is a pilot program demonstration that, if it works well, could possibly be expanded. It is already in effect.

The first phase of the demonstration is on DME claims related to oxygen equipment and supplies and glucose testing supplies in Jurisdictions C and D. Under this demonstration, selected suppliers will have the opportunity to participate in a formal recorded telephone discussion with QIC and C2C and offer verbal testimony. The selected DME suppliers will be able to discuss the facts of the case and provide any additional documentation that would assist in reaching a favorable determination.

The second phase of the demonstration is with reopenings. C2C will be able to look at those claims found unfavorable or partially unfavorable that are in the ALJ. They can only go back to January 1, 2013, which is the C2C decision date on the letter, not the date of service. The contractor will only open up those claims that they feel can be overturned to a favorable decision. Don’t worry if you are a select supplier, as you will not lose your place in line at the ALJ if they don’t see where the claim can be found favorable.

What To Expect If You’re a Selected Supplier

For both phases of this demonstration that is scheduled to run through 2016, selected suppliers will receive a letter that invites them to a scheduled phone discussion. The supplier has 14 days to respond to the letter. If the supplier opts not to have a phone discussion, a response is still needed; you should follow the instructions in the letter. If no response is received, the contractor will reach out to the supplier. The discussion can be about technical issues or medical necessity, meaning if something is missing or can be obtained easily by the supplier, this can be accomplished during the discussion with the reviewer. 

Instead of the 60-day timeframe, if the appeal was selected for this demonstration, there is a 120-day timeframe to allow for scheduling, the discussion to take place, additional documentation to be submitted and to review the testimony and additional documentation that was received through the discussion process.

For those larger DME suppliers that have multiple NPIs, the contractor is only looking at five NPIs and five claims per NPI. 

Continue to submit your appeals as normal. Watch for those letters in case you are selected to participate in the phone discussion where you can give a testimonial as to why the claim is payable. The reviewer nurse will then take that information and make a determination. If the decision does come back as unfavorable, you still have appeal rights, which means going to the next level at ALJ. Remember, they are starting with only two product categories as a pilot in two jurisdictions: oxygen equipment and supplies and glucose testing supplies in Jurisdictions C and D.

Check out the C2C Innovation Solutions website for information.

Ronda Buhrmester
[email protected]