EEOICPA BULLETIN NO. 07-14

 

Issue Date:  April 17, 2007

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Effective Date: April 17, 2007

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Expiration Date: April 17, 2008

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Subject: Fee Schedule Appeal Process (Medical Bill Pay)

 

Background: As part of the medical bill payment process, the EEOICPA regulations provide for the appeal of fee schedule reductions. To maintain consistency, record responses, and track fee schedule appeals, it has become necessary to develop procedures consistent with DEEOIC regulations.

 

References:  20 C.F.R. Part 30.712

 

Purpose: The purpose of this bulletin is to provide procedural guidance to all staff regarding the processing and tracking of fee schedule appeals. The final step in this bulletin includes action required of the OWCP Regional Directors, who are included in the distribution list.  

 

Actions:

 

1.  When a fee appeal request letter is received by ACS (DEEOIC’s bill payment contractor), ACS will store an electronic copy of the appeal letter in the Stored Image Retrieval system (SIR)  linked to the remittance voucher, and will send a printed copy of the letter to DEEOIC Central Bill Pay, Attn: Payment Systems Manager.

 

2. For each fee schedule appeal letter received, the Payment Systems Manager (PSM) will create a record, and these records will be maintained in a tracking system (spreadsheet or database) created for this purpose.

 

3. The PSM will review the fee appeal request to determine if the provider has met any of the conditions below which justify a reevaluation of the amount paid. These three conditions, as found in 20 C.F.R. 30.712, are:

 

(a)         The service or procedure was incorrectly identified by the original code; or

 

(b)         the presence of a severe or concomitant medical condition made treatment especially difficult; or

 

(c)         the provider possesses unusual qualifications (i.e. possesses additional qualifications beyond Board-certification in a medical specialty, such as professional rank or published articles.)

 

4. Within 30 days of receiving the request for reconsideration, the PSM will prepare a response to the medical provider outlining DEEOIC’s decision to either:

 

(a)         Approve an additional payment amount; in this instance, the PSM will generate a draft letter for the District Director’s (DD) signature, informing the provider of the approval for additional payment. [Where an additional amount is found to be payable based on unusual provider qualifications, the DD should determine whether future bills for the same or similar service from that provider should be exempt from the fee schedule and should consider placing that provider on review.] The PSM will also prepare a memorandum for the case file stating the findings and the basis for the approval of the additional amount or,

 

(b)         Deny any additional payment; in this instance the PSM will prepare a draft letter decision for the DD’s signature, advising that additional payment is denied, based upon the provider’s failure to establish one of the conditions listed above, in Item 3.(a,b,c). Where additional payment is denied, the letter decision must contain a notice of the provider’s right to further review similar to the following:

 

                   If you disagree with this decision, you may, within 30 days of the date of this decision, apply for additional review. The application may be accompanied by additional evidence and should be addressed to the Regional Director, District _________, Office of Workers’ Compensation Programs, U.S. Department of Labor, [Insert appropriate Regional Office address and Zip Code.]

 

 

5. The draft approval or denial letters will be prepared by the PSM, for the signature of the District Director whose office has control of the claim file(s) being addressed in the decision(s). The PSM will send the draft letter (via email) to the District Director for review, signature and mailing. The DD will place a copy of the signed letter in the case file and will also return (via email) a scanned copy of the signed letter, to be retained by the PSM.

 

6. The PSM will continue to track the status of any fee schedule appeal case, and will maintain an electronic copy of all correspondence. This will include a copy of the draft letter and a scanned copy of the signed letter mailed by the DD.

 

7. If a denial is subsequently appealed to the Regional Director (RD), the RD must consult with the PSM to obtain copies of relevant bills and documents, and to discuss the appeal. The PSM will also provide the RD with a copy of the denial letter sent by the DD. This can be handled via email.

 

8. After consultation with the PSM, the Regional Director will prepare a written response to the provider within 60 days of receipt of the request for review. Where additional payment is denied at the regional level, the letter decision from the RD should advise the provider that the decision is final and is not subject to further review. The RD will forward a scanned copy of the signed letter decision to the PSM. That response will also be retained by the PSM as part of the appeal record.

 

9. The final outcome of each appeal letter will be recorded in the PSM tracking system to indicate:

 

(a)         additional payment made

(b)         denial letter sent by DD

(c)         appeal letter sent to RD

(d)         time limit (30 days) has expired for appeal to RD

(e)         denial letter sent by RD

(f)         the final disposition date for each appeal letter

 

 

Disposition:  Retain until incorporated in the Federal (EEOICPA) Procedure Manual.

 

 

 

 

PETER M. TURCIC

Director, Division of Energy Employees

Occupational Illness Compensation

 

 

Distribution List No. 1: Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Regional Directors, Operation Chiefs, Hearing Representatives, and District Office Mail & File Sections