C2C Innovative Solutions Gives Suppliers a Bigger Voice in Defending Claims

Posted on in Billing/Reimbursement

By: Ronda Buhrmester, Reimbursement Specialist, VGM & Associates

At the Medtrade Spring Jurisdiction D council meeting, C2C Innovative Solutions, Qualified Independent Contractor (QIC), introduced a two-phase demonstration to give select suppliers an enhanced opportunity to provide critical feedback and increased analysis of denied claims. Currently there is a demonstration project that consists of two phases in Jurisdiction C and D for diabetic testing strips and oxygen equipment only. 

The first phase has allowed selected DME suppliers the opportunity to participate in a formal, recorded telephone discussion with C2C and to offer verbal testimony. The selected suppliers are able to discuss the facts of their claim cases 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 open only those claims they feel can be overturned to a favorable decision. If you are selected as a supplier, don’t worry as you will not lose your place in line at the ALJ if they don’t see where the claim can be found favorable. 

Keep in mind, these current phases have been only for oxygen equipment and diabetic testing strips in Jurisdictions C and D.

What to expect if you’re a selected supplier

For both phases of the demonstration, which is scheduled to run through 2016, selected suppliers will receive a letter inviting them to a scheduled phone discussion. If you receive the letter, you have 14 days to respond. If you opt not to have a phone discussion, a response is still needed, so follow the instructions in the letter you receive. If you do not respond, the contractor will reach out to you. The discussion can be about technical issues or medical necessity, meaning if something is missing or can be obtained by you, 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 C2C received through the discussion process.

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 testify as to why a 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.

Updates from Medtrade Spring

At the Jursdiction D DAC meeting at Medtrade Spring, C2C shared that since the demonstration started, there have been 12,000 claims reviewed, and 80 percent of those claims were overturned in favor of the supplier, compared to an overturn rate of 30 percent through the traditional process. 

C2C also shared that the demonstration will be expanded to other areas, except power wheelchairs, soon. Please stay tuned for the effective date.

Next steps

If you currently have claims at the ALJ for any product category except power wheelchairs, you can request the C2C to review for a possible reopening by visiting and completing a form. If you have a large volume of claims sitting at C2C or ALJ, please contact me. I would be happy to connect you with someone at C2C, and they will let you submit a spreadsheet instead of completing forms for each individual case. If C2C is unable to reopen the claim, you will not lose your place in line at the ALJ.

If you are in Jurisdiction A or B, you are considered a control group for this demonstration. However, requests can be submitted for CMS to consider opening up this project to your jurisdiction. What you need to do is email C2C with the request to expand it to Jurisdiction A or B. Send the requests to [email protected]. Make sure to send in your requests!!

An important note: C2C uses the contact information submitted with the appeal letter. Make sure all your staff is aware of this. Reason being is there has been concern with the lack of response by some suppliers to the letter and telephone calls from C2C.  

This program benefits you! This is a good opportunity for suppliers, especially those that have many claims pending at reconsiderations and at the ALJ.

Check out the C2C Innovation Solutions website for information.  Feel free to contact me as well for more information or if you have any further questions.

Ronda Buhrmester
[email protected]