Transcript Denials, Appeals, Cash - COA Administrators Network

Denials, Appeals, Cash
Part 1
UNYSMO
Agenda
Advanced Financial Counseling
 Denials Q1 Medical and Radiation
Oncology
 Appealing Denials
 Cash Management

Market Trends
More patients are paying out-of-pocket
Changes in self-payments including:




Increased co-pays
Coinsurance payments
Deductible payments
Out-of-pocket payments
for uninsured
Mean Health Insurance Costs Per Worker Hour
for Employees with Access to Coverage, 19992005
Source: Kaiser Family Foundation analysis based on data from the National Compensation Survey, 1999-2005, conducted by the Bureau of
Labor Statistics.
Out of Pocket Costs Are Too High (2005)
Percent of adults (age 19-64) reporting in past 12 months:
NOTE: Insured includes those with public or private insurance coverage.
SOURCE: Kaiser Commission on Medicaid and the Uninsured analysis of the Kaiser Low-Income Coverage
and Access Survey 2005: National All-Income Sample.
Market Trends
More patients are paying out-of-pocket
 Deductibles are growing due to HDHP’s.
 1.3 million have an HSA
(1% of total insured population)
 8.5 million have high deductible plans without
HSA’s.
(Per the Employee Benefit Research Group – 2006 Survey)
 $1 billion dollars invested in HSAs by
Americans
(according to data gathered by inside Consumer-Directed Care (ICDC)
newsletter Feb. 24 issue )
Impact of the Rise in Unemployment on Health
Coverage, 2007 to 2009
3.9
3.6
3.6%
=
National
Unemployment
Rate Increase
since 2007
(from 4.9% in
Dec-07 to 8.5% in
Mar-09)
Decrease in
Employer
Sponsored
Insurance
(million)
8.9
&
Medicaid Uninsured
/CHIP
Increase
(million)
Enrollment
Increase
(million)
Note: Totals may not sum due to rounding and other coverage.
Source: John Holahan and Bowen Garrett, Rising Unemployment, Medicaid, and the Uninsured, prepared for the Kaiser
Commission on Medicaid and the Uninsured, January 2009.
Uninsured Rates Among the Nonelderly,
by State, 2006-2007
NH
VT
WA
MT
MN
OR
ID
SD
MI
RI
CA
CO
IL
KS
NM
OH
IN
WV
NC
TN
MS
AK
AL
CT
NJ
DE
MD
DC
SC
AR
TX
VA
KY
MO
OK
AZ
PA
IA
NE
NE
NV
MA
NY
WI
WY
UT
ME
ND
GA
LA
FL
HI
US Average = 18%
≥ 18% (18 states)
13-17% (19 states )
< 13% (13 states & DC)
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban
Institute analysis of the March 2007 and 2008 Current Population Survey.
Two-year pooled estimates for states and the US (2006-2007).
Physicians’ Net Income from Practice of Medicine and
Percent Change vs. Private Sector Occupations (1995,
1999, 2003)
Average Reported Net Income
(dollars)
Average Net Income, Inflation
Adjusted (1995 dollars)
1995
1999
2003
1995
1999
2003
1995
1999
2003
All Patient Care
Physicians
180,930
186,768
202,982
180,930
170,850
168,122
-5.6%*
-1.6%
-7.1%*
Primary Care
Physicians
135,036
138,018
146,405
135,036
126,255
121,262
-6.5*
-4.0*
-10.2*
Specialists
210,225
218,819
235,820
210,225
200,169
195,320
-4.8*
-2.4
-7.1*
Medical
Specialists
178,840
193,161
211,299
178,840
176,698
175,011
-1.2
-1.0
-2.1
Surgical
Specialists
245,162
255,011
271,652
245,162
233,276
224,998
-4.9
-3.6
-8.2*
N/A
N/A
N/A
N/A
N/A
N/A
4.3
2.5
6.9
Private Sector
Professional,
Technical,
Specialty
Occupations^
Percent Change in InflationAdjusted Income
*Rate of change is statistically significant at p<.05.
N/A: Not available.
^The Bureau of Labor Statistics (BLS) Employment Cost Index of wages and salaries for private sector “professional, technical and specialty”
workers was used by the Center for Studying Health System Change (HSC) to calculate estimates for these workers; significance tests were
not available for these estimates. HSC calculated inflation-adjusted estimates using the BLS online inflation calculator
(http://146.142.4.24/cgi-bin/cpicalc.pl).
Source: Center for Studying Health System Change, Community Tracking Study Physician Survey, Losing Ground: Physician Income, 19952003, Tracking Report No. 15, June 2006, Table 1, at http://www.hschange.com/CONTENT/851/851.pdf.
Declining Physician Compensation
Source: MGMA Median Compensation Survey
Market Trends

Below are the estimated recovery percentages by
control point for inpatients
◦
◦
◦
◦
◦

Pre-Admission (100%)
Admission (75-80 %)
Inpatient (65-75%)
At Discharge (60-70%)
One Month After Discharge (<40%)
The bottom line is: when you are in the patient’s
mindset, you can collect!
What can you do to gain success in your
collections efforts?
Think that the Financial Counseling Process does not end until the $$ is in the bank
FIRST STEPS


Ensure that your physicians are committed
to collecting money---that means they
cannot give out the double message to
patients. It does not help anything if they tell
patients not to ever worry about money.
There message should be…”our financial
counselor will assist you with finding ways to
pay for your care…”
Nothing will improve without provider
support.
Pre-Visit
Collect demographic information.
 Collect insurance information.
 Explain conditions of treatment meaning
financial terms.
 Clarify who is responsible for the bill.
 Verify insurance and benefits.
 Obtain authorizations and/or referrals for
the services you know about.

Insurance Verification Check List

Patient has the insurance they say they do and it is primary with effective
date

Insurance address for bill

Plan type: HMO/PPO/other

Deductibles impacting care delivered in the office, e.g. IV drugs, radiology,
labs, chemotherapy administration

Episodic patient cost sharing for care delivered in the office, e.g. flat copays
for Rx; coinsurance payments, amount

Lifetime, annual or episode out of pocket maximum

Catastrophic coverage (yes/no)

Benefit caps: lifetime or other

If possible, patients’ current status regarding deductibles and out of pocket
maximums; current progress toward caps

Insurer requirements: Prior authorization; certification; notification; case
management, step therapy

Specialty pharmacy preference for patient costs, pharmacy billing.
Do You Want to Treat?
Insured patients---yes!
 Underinsured/ uninsured

◦ Do they have $$$ or assets? Will they pay?
◦ Do they qualify for Medicaid?
◦ Do they qualify for other assistance in your
state?
◦ Can they be insured by patient assistance or
Foundations?
◦ Can they go on a trial?
Remember: Foundations will fund premiums
only if there is a specific request
Process Improvements:
Pre-Visit
If
uninsured, begin the process before the
patient arrives…
“To best serve you at this practice, we
need for you to bring in your tax returns
for the last three years or another form
of proof of income when you come to
the office for your first visit. We can try
to get funding for your treatment, if you
qualify…”
Process Improvements:
Pre-Visit

Deliver a consistent message to patients
about their financial responsibility and
continually educate them on their specific
benefit plan. Each patient that visits
should sign a conditions of treatment that
includes:
◦ Obligation to pay patient costs
◦ Obligation to obtain referrals
◦ Obligation to inform you of change in
insurance, employment or care status
◦ Be party to a collection effort, if they
fail to pay their bill.
Process Improvements:
The First VISIT
Provide detailed explanations where appropriate.


◦
Train registration staff on how to present the conditions of treatment
forms and create scripts to support the process
◦
Allow time in the registration process for the registrar to more fully review
the forms with the patient or consult with the financial counselor.
◦
Have the forms signed and return a copy to the patient.
Use a Patient Financial Obligation Statement that they should
sign prior to their first TREATMENT
Tip: Statement content can vary from illustrating co-pay,
deductible and coinsurance information to much more
complex calculations, such as those that regimen
specific and payer-specific (contractual database or use
your ERA data).
Process Improvements:
FIRST VISIT

For insured patients, do the following:
 Review treatment plan thoroughly (if and when it is available)
 Explain treatment alternatives, if there are any.
 Calculate out-of-pocket costs if you know them and provide the
patient with approximate time frame for these costs.
 Inform patient of the obligation to pay patient costs at the time of
the visit, if possible.
 Take a deposit for the first round of chemo if it is occurring that day.
 Take credit cards in case bills are not paid or if the patient prefers to
pay by credit card.
 Answer any questions the patient or family may have.
 Perform a credit check, if the patient will owe more than benchmark
amount (≥ $5000)
Process Improvements:
patient Financial Counseling
Collecting money from patients can be both a challenge and
a delicate situation if not handled properly.
 Remember their care
is a higher priority
than collecting
payment, but
collecting cannot be
ignored.
Process Improvements: Financial
Counseling

Sample script with insurance:
“We have verified your benefits.The good
news is your insurance company is covering
the majority of your bill. Today all you are
responsible for is $XX. How would you like to
pay today: cash, check, or credit card?”

Increase points of collections----ever
thought of putting an ATM outside of your
office or in the waiting room?
REMEMBER: Patients with insurance often
think their bills are paid!

Uninsured and Underinsured: The Visit

These patients can be treated in the hospital--but do not give up too easily…they need a
financial interview and they need to bring the
following:
Three years of tax statements or proof of income
Statements of working assets---IRAs, 401K, life
insurance, annuities, etc., if you consider them r the
programs for the patients do
Bank references for patients who have a high self-pay
balances
Credit cards
Proof of Medicaid rejection, if they are going the PAP
route
High Balance Patients—The VISIT

UNINSURED PATIENTS: DO THEY QUALIFY FOR PAP
or FOUNDATIONS?


The 2009 Poverty Guidelines for the
48 Contiguous States and the District of Columbia
Persons in family Poverty guideline
1
$10,830
2
14,570 = 500% = $72,050
3
18,310
4
22,050
5
25,790
6
29,530
7
33,270
8
37,010

For families with more than 8 persons, add $3,740 for each additional person.









High Balance Patients—The VISIT

Some PAPs besides having an income
requirement have an asset requirement.
What is this?
◦
◦
◦
◦
◦
Not the patient’s house or car
Retirement funds: 401K, IRA, SEP
Stocks, marketable securities
Other real estate
Other investment transactions
High Balance Patients—The VISIT

Why do all of this?
◦ Manage the patient and provider expectations
◦ Get patient through the process faster…right
now it takes a long time
◦ Be prepared with next steps for patients who
do not qualify
◦ But, bottom line, keep as many folks with you
as possible.
Analyze
Value Stream Process Map
99% of the Process Time Involves Two Process Steps
Patient is referred
to Oncologist and
Dx/Tx determined
Patient
completes
patient portion
2160 min
(36 hrs)
Financial &
Insurance
Verification
32 min
Locate &
Evaluate
Assistance
Programs
Call/ascertain
Program
Requirements
62 min
44 min
Entire
application
submitted
Notification
of approval
or denial
11400 min
(190 hrs)
(7.9 days)
Practice
completes
office portion
33 min
1%
16%
Percent of Processing Time
Source: E-Expert Reimbursement Partners 2008 PAP Survey
83%
Alternatives for Patients
Other facilities
 Clinical Trials
 Treat them anyway
 Working their assets---what?

Working Assets
Viatical and Other Insurance Settlements
 Restructuring Retirement Funds
 Payment Plans
 Automatic Credit Card Withdrawals

What is a life or viatical settlement?

A life or viatical
settlement is a
proven financial
strategy that enables
eligible policy holders
to sell their life
insurance to a funding
institution and receive
a lump sum of cash.
This also means the
patient does not need
to pay premiums.
What is the difference between a life and a
viatical settlement?

Life settlements generally involve individuals over the
age of 65.

Viatical settlements generally involve individuals of any
age who are terminally or chronically ill.
Please note that the definitions of these terms vary by state.
Financial Counseling & collections




The financial counseling
process does not end after
the first visit.
Any patient with an
outstanding balance over 30
days of over $5000 should be
counseled.
Alternatives involving credit
and assets should be offered.
Also remember that some
patients will spend down to
Medicaid levels.
Increase your collections

Train your staff on how to ask for payment. Introduce
scripts if necessary. Prepared answers for the more
common objections for non-payment will give your staff
the confidence to be more assertive.
PUT INCENTIVES IN PLACE
For lowering patient balances or DSO
 For successful PAP applications in less
than 5 days
 For collection of patient balances over
$5-10K
 For lowering the number of patients that
are sent to the hospital
 For overall reduction in DSO or denials

Who Makes A
Good Financial
Counselor
Someone who understands practice finance and
collections.
 Someone who is tactful and empathizes well
with patients and caregivers
 Someone who can talk about finances without
wincing or being afraid to ask for what they need.
 Someone who does not give up easily.
 Someone with astute quantitative skills.

Make Everyone A FC

Have a Contract Book at your Front Desk
◦ Pictures of Insurance Cards
◦ Pre-Auth, Referrals Needed With E-mails or
Telephone Numbers
◦ Employers Who Use, if Applicable
◦ Contract Copays and Deductibles
◦ In-network, Out-of-Network
◦ Contracted Rates (for billing)
◦ Contracted Pharmacies


Discharge Area with scripts, appointments,
and charging.
Signs in waiting room.
Payor Data from RemitDATA
Claim Lines: Medicare – $3.4 Million
Commercial – $4.6 Million
 Paid $ Amt: Medicare - $390 Million
Commercial – $818 Million
 Claims Adjudicated from 01/01/200903/31/2009

© 2009, RemitDATA, Inc. ALL RIGHTS RESERVED.
Overall Denial Rate: Medicare
What’s Happening
18—Duplicate claims: good news and bad
news
 16---Missing information: a lot still H&H
for anemia drugs
 50—Medical necessity: wrong diagnosis or
off-label
 109—Wrong payers
 15—Unbundled codes

Problem Areas




Denial Code 18: Duplicate Claims
◦ Boring
◦ But, creates extra effort in the practice.
Denial Code 16: Missing Information
◦ ESA problems
◦ Other anemia drugs
Denial Code 50: Medical Necessity
◦ Wrong diagnosis
◦ Poor understanding of LCDs
◦ MAC conversion LCDs
Denial Code 109: Not covered by this payer
◦ Must verify insurance on all Medicare patients at the beginning of the year.
Solutions to Medicare Issues
Think about the cost of duplicate claims
in your practice—how many times are
they touched?
 Make someone reviews LCDs once per
month or is on the MAC ListServ.
 Verify a patient’s Medicare in the
beginning of the year AND for every new
patient. It is an effort but is better than
sitting on hundreds of dollars in claims.

Focus On Problems: Aranesp
Focus On Problems: EPO
ESA Results Q1


Epoetin alfa is similar to Darbepoetin and has actually
worsened this quarter!
Specific problems for ARANESP® but quite similar for
EPO:
◦
◦
◦
◦
◦

47% of denials are medical necessity
18% are duplicate claims
16% have missing H&H results
9% have incorrect modifiers
3% are wrong payer.
So, we can conclude that either folks do not understand
the H/H requirements (≤ 10/30) or they choose to
ignore them.
© 2009, RemitDATA, Inc. ALL RIGHTS RESERVED.
Best Practice: ESA “Gatekeeper”

What is that?
◦ If you have physicians who give ESAs either
because they do not know the lab results OR
they choose to ignore them, you need one or
more gatekeeper(s).
◦ This means that patients may not get ESAs
until the “gatekeeper” has approved them
after reviewing the latest lab result.
90772
90772: What’s The Problem?

Surprise! Worst of all drug admin for
Medicare…
◦
◦
◦
◦
◦
17% denied = Medical necessity
17% denied = Wrong Payer
17% denied = Missing information
16% denied = Qualifying service not billed
16% denied = Duplicate claim
90772 Solutions
It is an outdated code, in case you have
been asleep all year.
 Use modifier -59 if billed with other
drug administration services.
 Make sure it is on the same claim with
the drug administered.
 Make sure if two injections are given
that they are billed as 2 units, not on
separate lines, unless you are in Florida.

Commercial Denials
Commercial Denials
Denial Code 18: Duplicate Claims = 18%
 Denial Code 97: Code Is Bundled Into
Another Service = 17%
 Denial Code 16: Missing Information=
10%
 Denial Code B27 = Payment Requested
After Coverage is Terminated

Commercial Best Practices

Stop billing bundled codes!!!!!!!!!
◦ Stop billing for solutions with chemo and therapeutic infusions.
It is bad coding.
◦ Stop billing 96523 with drug admin. It is wrong.
◦ Check your Chargemaster Report for other wastes of time.


Ensure that the prior auth or cert number is on the
claim.
Ensure that patients tell you whether their insurance
status has changed EACH TIME THEY COME IN.
Good Job!
© 2009, RemitDATA, Inc. ALL RIGHTS RESERVED.
Denial Benchmarking Oncology Q1
35.00%
31.89%
32.95%
30.00%
24.38%
25.00%
22.90%
20.73%
19.91%
20.00%
Commercial
Medicaid
Medicare
15.00%
10.00%
10.28%
9.67%
8.15%
8.48%
7.50%
8.48%
8.69%
8.46%
7.24%
5.49%
6.24%
6.20%
5.00%
0.00%
Drug Admin
Drugs
Consults
© 2009, RemitDATA, Inc. ALL RIGHTS RESERVED.
Estab Visits
Rad Onc
Lab
DSO Trend Analysis
70
60
50
40
Medicare
Commercial
30
20
10
0
Q1 2008
Q2 2008
Q3 2008
© 2009, RemitDATA, Inc. ALL RIGHTS RESERVED.
Q4 2008
Q1 2009
DSO By Category Q1 Oncology
100
90
80
70
60
50
Medicare
40
Commercial
30
20
10
0
Drug Admin
Consults
Estab Visits
Hospital Visits
© 2009, RemitDATA, Inc. ALL RIGHTS RESERVED.
Drugs
Lab
Rad Onc
What is the Problem?
Yikes! Medicare pays drugs at least 60
days AFTER you pay for them!
 Working old ESA claims…
 Drug admin new codes are not the
problem.
 What is the deal with E/M?
 Rad Onc is a huge problem and it is not
just IMRT. 77427 (Treatment
Management) DSO is 148 days.

Read It And Weep!
1st Quarter Drug DSO
46
All Drugs
60
42
Gemcitabine
65
40
Trastuzumab
52
Docetaxel
58
47
Oxaliplatin
73
DSO COMM
61
DSO MCR
73
Darbepoetin
129
37
39
Pegfilgastim
43
Rituximab
47
51
53
Bevacizumab
0
20
40
60
80
100
120
140
Best Practice: Drug Billing

Each claim should be audited prior to billing
◦
◦
◦
◦
Correct drugs billed
Correct admin codes billed
Modifiers applied
LCD for Medicare checked and correct diagnosis
on claim
◦ ABN signed for off-label use; guidelines used in
chart
◦ Prior auth number obtained and billed for
commercial
Hospital Admits
DSO of Hospital Admits
118
120
118
100
80
76
60
49
56
DSO MCR
51
40
20
0
Hospital Admit Level 1
Hospital Admit Level 2
Hospital Admit Level 3
DSO COMM
What’s Going On Here?
Doctors and other providers do not think
this is $$, but, if it happens for all visits, it
is $$$. Represents over $9.3 million for
all customers.
 Offices use poor communication tools for
hospital visits.
 Offices wait for dictation to come in from
the hospital.

Best Practices
Physicians use a Superbill by patient and
must hand them in EVERY WEEK or they
are penalized.
 This will avoid A/R issues and other audit
issues.
 A Superbill can be found at
http://communityoncology.info/category/li
brary/

Huh? Talk Me Down!
DSO Office Consults
100
97
90
80
73
70
60
54
84
76
45
35
50
40
35
36
DSO MCR
36
30
DSO COMM
20
10
0
DSO COMM
Office Consult
Office Consult
Level 1
Level 2
Office Consult
Level 3
DSO MCR
Office Consult
Level 4
Office Consult
Level 5
Possible RAC Issue?
Consults Versus New Visits
18806
20000
19042
18000
16000
14000
9794
12000
10000
8000
New
6000
360
4000
2000
2646
3422
Consults
5147
348
3442
0
1673
New Visits/
Consults Level 1
New Visits/
Consults Level 2
New Visits/
Consults Level 3
Consults
New
New Visits/
Consults Level 4
New Visits/
Consults Level 5
Consultations
Transfer of Care

A transfer of care occurs when a physician or NPP requests that another physician
or NPP take over the responsibility for managing the patient’s complete care for the
condition, and does not expect to continue treating or caring for the patient for
that condition.

When this transfer is arranged, the requesting provider is not asking for an opinion
or advice to personally treat this patient and is not expecting to continue treating
the patient for the condition. The receiving physician or NPP shall document this
transfer of the patient’s care in the patient’s medical record or plan of care.

If a transfer of care occurs, report the appropriate new or established patient visit
code should be billed based on place of service.

51 Specialty Societies have objected to this language (including the AMA, ASCO, and
ASH), but this Transmittal is still in effect and has been the Medicare rule since
1/1/2006.
Consult vs. Referral
Referral (New Pt Visit)
Consult
Diagnosis and/or treatment
known at the time of the referral
for a new or existing problem.
Referring physician wants to
ascertain differential diagnoses
and/or treatments for the patient
for a new problem. Documents
the consultation request as part
of their treatment plan.
Treatment known at the time of
the referral with or without report
by consultant.
Treatment plan to be
communicated by report by
consultant to the referring
physician.
Referring physician does not
expect to further treat the patient
for this particular diagnosis.
Referring physician will continue
to treat the patient after the
consultation.
Referring physician out of the
picture.
Consultant generates a report
with their opinion and plan for
treatment and may update the
referring physician periodically .
Overview of Payment Q1
Denials Are All Around!
Denied claims as a percent of claims
10% -15% or more in many practices
 Medicare alone denies approximately
6.3% of all line items billed
 Estimated cost to work a denial is $25
- $30 per claim

PART A & PART B PROCESS
(Non-Expedited)
Beneficiary receives the service
Medicare contractor (fiscal intermediary or
carrier or MAC) issues initial determination
explaining whether Medicare will pay for a
service already received.
 Beneficiary has 120 days to request
redetermination by contractor. Provider may
also request redetermination


◦ Appeals will be consolidated
◦ Time frame may be extended for “good cause”

Contractor has 60 days to issue
redetermination
PART B APPEALS
(cont.)

If redetermination is unfavorable can request
a“reconsideration” by Quality Independent
Contractor (“QIC”)
◦ 120 days to request reconsideration
◦ Beneficiary & provider appeals will be consolidated
◦ Time may be extended for good cause
◦ Must fill out a reconsideration form which is available at
http://www.cms.hhs.gov/cmsforms/downloads/cms20033.pdf

QIC must issue decision within 60 days.
◦ Parties may request escalation to ALJ if time frame not
met
◦ 60 days to request review by ALJ
ALJ HEARINGS





Hearings conducted by Medicare ALJs in DHHS Office
of Medicare Hearings and Appeals
Minimum amount disputed must be $120 in 2008; $124
in 2009.
ALJs are in 4 regional offices, not local offices
Must fill out the ALJ request form
(http://www.cms.hhs.gov/cmsforms/downloads/cms20034ab.pdf)
For Part A and Part B claims, ALJ must issue decision
within 90 days – with exceptions
◦ No time limit if request for in-person hearing granted
ALJ HEARINGS (cont.)
For ALJ hearings under Parts A, B, C & D
 Amount of claim must be at least $120 in 2008 (changes
annually)
◦ Subject to annual increase
◦ Can aggregate certain claims

Hearings conducted by video teleconferencing (VTC) if
available, or by telephone
◦ ALJ assigned to case has discretion to grant request for inperson hearing
APPEALS PROCESS – BEYOND THE
ALJ HEARING

If ALJ decision is unfavorable, have 60 days to request an
Appeals Council review (address will be in the rejection
letter)
◦ Must be in writing within 60 days after the ALJ decision,
◦ Appeals Council reviews the record concerning only those
issues, unless unrepresented beneficiary requests.

If Appeals Council decision is unfavorable, have 60 days
to request review in federal court
◦ Must meet amount in controversy requirement
 Amount may increase each year ($1180 in 2008)
CALCULATING TIME FRAMES
Time frames are generally calculated from date
of receipt of notice
 5 days added to notice date
 Time frames sometimes extended for good
cause, examples include:

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Serious illness
Death in family
Records destroyed by fire/flood, etc
Did not receive notice
Wrong information from contractor
Sent request in good faith but it did not arrive
MEDICARE ADVANTAGE APPEALS

“Organization determination” is initial determination
regarding basic and optional benefits
◦ Can be provided before or after services received
◦ Issued within 14 days

May request expedited organization determination if
delay could jeopardize life/health or ability to regain
maximum function.
◦ Plan must treat as expedited if requested by doctor
◦ Issued within 72 hours
MEDICARE ADVANTAGE (MA)


Request reconsideration w/i 60 days of notice of the organization
determination.
Reconsideration decision issued within
◦ 30 days for standard reconsideration.
◦ 72 hours for expedited reconsideration.

Unfavorable reconsiderations automatically referred to
independent review entity (IRE).
◦ Time frame for decision set by contract, not regulation

Unfavorable IRE decisions may be appealed
◦ to ALJ
◦ to MAC
◦ to Federal Court
MEDICARE ADVANTAGE (MA)

Fast-Track Appeals to Independent Review Entity (IRE)
before services end for
◦
◦
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
Terminations of home health, SNF, CORF
Two-day advance notice
Request review by noon of day after receive notice
IRE issues decision by noon of day after day it receives appeal
request
60 days to request reconsideration by IRE
◦ 14 days for IRE to act
MEDICARE ADVANTAGE
GRIEVANCE PROCEDURES

Grievance procedures to address complaints
that are not organization determinations.
◦ 60 after the event or incident to request grievance
◦ Decision no later than 30 days of receipt of grievance.
◦ 24 hours for grievance concerning denial of request
for expedited review.
PART D APPEALS PROCESSOVERVIEW



Each drug plan must have an appeals process
◦ Including process for expedited requests
A coverage determination is first step to get into the appeals process
◦ Issued by the drug plan
◦ An “exception” is a type of coverage determination
Next steps include
◦ Redetermination by the drug plan
◦ Reconsideration by the independent review entity (IRE)
◦ Administrative law judge (ALJ) hearing
◦ Medicare Appeals Council (MAC) review
◦ Federal court
PART D APPEALS PROCESS –
COVERAGE DETERMINATION

A coverage determination may be requested by
◦ A beneficiary
◦ A beneficiary’s appointed representative
◦ Prescribing physician

Drug plan must issue coverage determination as
expeditiously as enrollee’s health requires, but no later than
◦ 72 hours standard request
 Including when beneficiary already paid for drug
◦ 24 hours if expedited- standard time frame jeopardize life/health of
beneficiary or ability to regain maximum function.
EXCEPTIONS: A SUBSET OF
COVERAGE DETERMINATION



An exception is a type of coverage determination and gets enrollee
into the appeals process
Beneficiaries may request an exception
◦ To cover non-formulary drugs
◦ To waive utilization management requirements
◦ To reduce cost sharing for formulary drug
 No exception for specialty drugs or to reduce costs to tier
for generic drugs
A doctor must submit a statement in support of the exception
PART D APPEALS - COVERAGE
DETERMINATIONS ARE NOT AUTOMATIC

A statement by the pharmacy (not by the Plan)
that the Plan will not cover a requested drug is
not a coverage determination
◦ Enrollee who wants to appeal must contact drug plan
to get a coverage determination
◦ Drug plan must arrange with network pharmacies
 To post generic notice telling enrollees to contact
plan if they disagree with information provided by
pharmacist or
 To distribute generic notice
PART D APPEALS PROCESS
NEXT STEPS

If a coverage determination is unfavorable:
 Redetermination by the drug plan.
 Beneficiary has 60 days to file written request (plan may accept
oral requests).
 Plan must act within 7 days - standard
 Plan must act within 72 hrs.- expedited
 Then, Reconsideration by IRE
 Beneficiary has 60 days to file written request
 IRE must act w/i 7 days standard, 72 hrs. expedited
 ALJ hearing
 MAC review
 Federal court
PART D GRIEVANCE PROCESS
Each drug plan must have a separate grievance
process to address issues that are not appeals
 May be filed orally /in writing w/i 60 days
 Plans must resolve grievances

◦ w/i 30 days generally
◦ w/i 24 hrs if arise from decision not to expedite
coverage determination or redetermination
USEFUL WEBSITES
www.medicare.gov
 www.medicareadvocacy.org
 www.healthassistancepartnership.org

Private Insurance Appeals
Appeals process must be outlined in the
contract.
 Sometimes, it is outlined on the payer’s
web site.
 Do not contract with a payer unless you
know their appeals process.

Appeals Process: Internal
Assess the denial and damage
 Gather data
 Draft letter
 Follow up
 Guerilla tactics

Assess Denial and Damage
Is this a rejection or denial? Know your reason
codes!
 Did the patient sign an ABN?
 Does this require an appeal? Or is it
unanswerable?

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No pre-auth
No coverage
Not eligible
Duplicate claim, unless a drug or admin unit problem
Assess the Denial/ Damage

Requiring a response
◦ Bogus coding
◦ Insurance limit reached, if cap is high
◦ Off-label, if supported by legitimate sources, like
approved compendia
◦ Medical necessity
◦ COBRA
◦ Pre-existing conditions, checking state law
◦ Contract violations
Draft Letter
Thoroughly review the record to ensure
documentation, legibility, and medical necessity
support are there.
 Collect data

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Clinical literature
Medicare laws, NCDs, LCDs, or local articles
Coding books and literature
Patient’s policy or benefit manual from employer
Paid EOBs from your own or neighboring practices
Agenda from KOL clinical meetings
Draft Letter

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Using chart documentation and data sources
draft a letter.
Use Medicare forms as necessary.
Review (unless it is an admin issues) the full
content of the letter with the provider and, if
necessary with the patient or caregiver.
Make corrections as necessary.
Always have the provider sign the letter, if
clinical issues are involved.
Follow Up
Send by signed mail and ensure that the
package was received.
 Mark in patient accounting file the date of
receipt and who signed the claim.

◦ Medicare--Follow up per policy.
◦ Commercial--Follow Up per contract or
every thirty days.
Guerrilla Tactics
Involve a lawyer---if only a cc
 Employer/ Union
 For Medicare or Medicaid

◦ Local representation
◦ HHS Regional Office
State Insurance Commissioner
 State Medical Society
 The Press

Stop the Bleeding
Do you have a denial management
strategy?
 Do you have an ERA (835) Analyzer?

◦ What are your top five denials by payer? by
dollar amount? by type?
◦ How do you prioritize denials? How long does it take
to address them?
◦ How many claims are improperly paid?

What is your plan to improve your denial
rate?
Find The Bleeding

Front Desk
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Poor demographics
No payer contact information
Insurance changes not tracked
Change of patient address
Wrong guarantor
No signature on financial commitment
form
Find the Bleeding

Insurance verification/ Billing
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Lack of authorization
Patient not eligible
MA not Medicare
Insurance ceiling not identified
Deductible fulfillment not tracked
Coordination of benefits
MSP
Catastrophic coverage
Find the Bleeding

Charge capture/billing
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Coding
Billing for supervising physician
Medical necessity
Support for unlisted codes
Timely filing
Duplicate claims
Inability to write off small amounts
Find the Bleeding

Clinicians
◦
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Change of diagnosis
Poor charge capture
Off-label use with no ABN
Dictation delays
No submission of hospital charges
Solutions

Front Desk/ Financial Counseling
◦ Technology
 Eligibility/verification products
 On-line eligibility verification
◦ Insurance company websites
Establish standardized registration polices,
procedures, processes and performance levels
 Ensure that registration staff is thoroughly
trained

◦ Insurance plans and requirements prior to treatment
◦ Plan requirements, e.g., referrals, authorizations
◦ Importance of correct demographics
Solutions

Charge Posting
◦
◦
◦
◦
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Computerized coding tools
Updated charge capture/Superbills
Claims editors
Claims “scrubbers”
Online access to Medicare policies for all providers
Strategies
Advanced Financial Counseling is a real key to
success…
 Focus on the problem as an organization-wide
opportunity to recover revenue---everyone has to
participate!
 Maintain an electronic folder of winning appeal letters
and make it an accessible library.
 Invest in systems to track, work and report denials, e.g.
835 analyzers
 Develop standards for reporting types of denials and
communicate this information
 Assign responsibility for denials and reward people for
improvements in denial rates
 Measure improvement on an ongoing basis.
