From: Phyllis Fredland [hpi@telerama.com]
Sent: Wednesday, July 28, 2004 11:41 AM
To: fdadocckets@oc.fda.gov
Cc: ahoward@aahomecare.org
Subject: Docket No. 2004s-0270

The following are our concerns with the published Plan for the Transfer of
Responsibility for Medicare Appeals:
 
     1.  We believe the breakdown of denials is the present breakdown  of
denials.  At one point more like 50% of the home health
          claims processed by the intermediaries were denied.  Therefore, I
wonder if CMS will commit to the 10% denial rate or what 
          will happen if the national denial rate goes higher.
 
     2.  Since the Secretary is a political appointee and the person to whom
the ALJs report, we believe that politics and the political 
    objectives of the administration could unduly influence the ALJ
decisions.
 
3.	According to the report, the most common reason for denying a claim
is not medically necessary and reasonable.  We believe that the
intermediaries need to explain in detail why the claim is not necessary and
reasonable.  We also believe that the intermediaries need to use the
standards of practice.  We have been asked many times what "not necessary
and reasonable" means by an ALJ and have used standards of practice as a
defense.  Therefore if the intermediaries were required to do these two
things, denials would decrease and reversals would too.
 
4.	They seem to have added a step to the denial process which will
lengthen it.  
 
5.	They say that reconsiderations will now be done by a qualified
independent contractor.  What makes a contractor qualified?  In the past the
independent contractor was another branch of the intermediary and since
personnel move around we actually could prove that the same person reviewed
the claim both times.  Therefore we suggest that the independent contractor
has to be completely different than the intermediary.
 
6.	What are the adjusted dollar amounts for appeal?  They need to
specify these.
 
7.	In addition by reducing the ratio of support staff to 4:1 per ALJ,
they are again slowing down the process so as to delay payment.
 
8.	By extending the timeframes for intermediaries to make
redeterminations and QICs to make reconsiderations, they are again delaying
payment.
 
9.	It looks like they will only have 1 ALJ per state.  In large states
that have great distances this will be a real problem.
 
10.	On what are dismissals based?  Who controls whether a record is
dismissed?
 
11.	Who will do the ALJ training?  It needs to be someone with medical
expertise as well as legal expertise and needs to be based on the law not
the regulations.
 
12.	What are the evidence requirements for providers and suppliers?
Unless we know this, we can't comment.
 
13.	We object to only electronic access.  Many times the machines crash.
What happens then?
 
14.	Are new decisions to be based on old decisions?  This will improve
uniformity and consistency.
 
15.	Video-teleconferencing or teleconference don't allow us to face the
experts.  By being able to challenge the experts, we have gotten them to
change their minds.
 
16.	We can not comment on the procedures or policies because we don't
know them.
 
17.	Is the only performance standard for an ALJ timeliness?
 
18.	To us when you say that performance appraisals  will be used as a
basis for training  you are saying that if the decisions aren't what the
secretary likes, retraining will be mandatory.  This is bias and prejudice.
 
Phyllis Fredland, R.N.,C. B.S.N., M.A.T,
Executive Director
Health Personnel, Inc.