Transcript Writing_the_Appeal_11_08

Writing an Appeal Letter
Lisa Bazemore, MBA, MS, CCC-SLP
Financial Impact
• eRehabData Appeals Tracking System:
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1331 denials logged
$24,847,122 dollars in claims
970 active appeals; $11,424,594 is currently under dispute
361 appeals have been closed
$6,312,757 was paid; $839,943 was denied
RAC Program
• National RAC Program Statement of Work
 Can’t request claims prior to 10/2007
 If denial is overturned, RAC loses payment for services
 Contractors are:
• Region A: Diversified Collection Services, Inc.
Initially working in Maine, New Hampshire, Vermont, Massachusetts,
Rhode Island, and New York
• Region B: CGI Technologies and Solutions, Inc.
Initially working in Michigan, Indiana, and Minnesota
• Region C: Connolly Consulting Associates, Inc.
Initially working in South Carolina, Florida, Colorado, and New
Mexico
• Region D: HealthDataInsights, Inc.
Initially working in Montana, Wyoming, North Dakota, South Dakota,
Utah and Arizona
Levels in Medicare Appeals Process
• Additional Development Request
 Fiscal Intermediary determines whether or not to pay the claim.
• Redetermination
 FI considers their original determination based on your appeal.
• Reconsideration
 The Qualified Independent Contractor considers your appeal.
• Hearing
 The Administrative Law Judge hears your appeal.
• Review
 The Medicare Appeals Council/Department of Appeals Board will
review the decision of the ALJ.
 Next, the Federal District Court will hear you case on disputed
claims.
*The Medicare Appeals Process is the same for Medicare A and Medicare B
claims
ADR
• The ADR is a written request from the FI for a medical record
which will be reviewed before payment is rendered.
• Frequently the ADR comes into the billing office or the medical
records department.
 Make sure ALL billing and medical records staff are aware of
what an ADR is and that they have to notify you (or
delegate) before sending out medical records.
• Tips:
 Documentation is time sensitive
 Note the source of the document
 Note the reason for the request if one is given
• Be aware:
 You have 120 days from the date of receipt of the notice.
This is presumed to be 5 days after the date of the notice.
ADR
• After you have carefully reviewed the FI correspondence:
 Follow the directions from the fiscal intermediary
completely.
• Once the record is copied review it again for
completeness and accuracy.
• Be sure that each page is copied front and back.
• Make a copy of the packet prior to sending it to the FI so
you know exactly what the FI had for review.
 Send the record to the FI contact as provided on the
letter using a delivery method that offers a tracking
number.
RAC Exception
• RAC Process:
 Charts will be requested and reviewed
 Determination will be rendered and sent to the
provider
 The provider has 15 days to rebut the decision of the
RAC before the RAC can request funds from the FI
 The RAC will consider the rebuttal
 If payment is denied, they will notify the FI
 Your claim is not a denial until the RAC requests funds
from the FI
 You have 120 days to appeal the decision from the
date of the remittance advice
Redetermination
• The Initial Appeal
 If the FI does not believe that your documentation
meets their criteria for payment, you will receive
notification that the claim was denied.
 At this stage you will send your record back to the FI
with a cover letter stating why you believe this claim
should be paid.
Reconsideration
• The initial appeal was considered and denied, so now you
seek reconsideration with a Qualified Independent
Contractor
 If the FI rejects your initial appeal, you can appeal the
claim at the QIC.
 This is the last stage when you can submit new
evidence, so consider what input may be available to
strengthen your claim.
Letters
• You can submit information that will help you make your case
for payment.
• Types of letters to include:
 Letter from the treating physician regarding the medical necessity of
the stay (ADR cover letter).
 Letter to explain the organization of the medical record being
submitted. Include for all appeals.
 Redetermination cover letter to rebut the reason for the initial denial.
 QIC cover letter to rebut the reason for the initial denial and the
denial at the redetermination stage.
 Letter from the referring doctor to address the reason for the referral
and perceived necessity for rehab.
 Letter from the patient or family member to indicate the need and
value of the rehabilitation stay.
Appeal Letter
• The appeal letter
 The body of the appeal letter should contain the following
information:
• Discuss the reason for the appeal
• Support the medical necessity of the claim according to the
conditions of participation
• Defend each week of care
• Explain that the admission was appropriate for your level of
care and services were reasonable and necessary
• Cite specific Medicare regulations such as the conditions of
participation in your letter where applicable
Preparing the Appeal –
MD Request Letter
• Request help from the doctors:
 Prepare a form letter to send to the treating physician to solicit
help with the appeals process.
• Explain the reason for the FIs request (probe, RAC, program
integrity)
• Let the doctor know that their opinion makes a difference and carries
weight with auditors.
• Provide a template of what to include.
• Indicate a deadline for their letter to be submitted to you so you can
include it with the appeals packet.
• Thank them profusely
• Be prepared to write the letter for them to sign.
Treating Physician’s Template
• Template should include
 Summary of etiologic diagnosis/reason for rehab.
 Pt. required:
24 hour availability of rehab MD for _______
24 hour availability of rehab nurse for _______
Multidisciplinary (or interdisciplinary) team approach
Coordinated plan of care
Intense level of therapy services
 Pt. demonstrated:
Significant practical improvement
Achieved realistic goals in an appropriate time frame
(LOS)
 Reason care could not be provided in a SNF
Preparing the Appeal –
ADR Cover Letter
• Example of MD Cover Letter:
 Explain reason for admission
• Ms. Example is a 67 year old female who underwent a
lumbar decompression and fusion on March 14, 2007 for
spinal stenosis and chronic back issues. Her full
procedure was that of an L3 through L5 decompression
and fusion from L3 to S1, as well as a TLIF at L4-5 and
L5-S1. Secondary to this surgery and her premorbid
condition, she was noted to have decreased mobility and
inability to be independent in ADLs. She had multiple
comorbidities, including requiring two liters of oxygen at
night chronically, a history of arrhythmias, history of
asthma, COPD, and depression.
Preparing the Appeal –
ADR Cover Letter
• Example ADR Cover Letter:
 Review the 8 conditions:
• She was evaluated by our preadmission team and was felt to be
an appropriate candidate for rehabilitation. The reason for this
was related to her recent surgery, long term back issues and
multiple comorbidities. It was felt that she required 24-hour
availability of a rehabilitation physician, secondary to her
respiratory issues, hypertension, history of cardiac arrhythmias
and for aggressive pain management. She also required 24-hour
availability of rehabilitation nursing to assist in pain
management, monitor her respiratory and cardiovascular status,
and provide education and training in ADL activities. Due to the
complexity of her back surgery and multiple comorbidities, it
was felt that she required a multidisciplinary team approach with
a coordinated plan of care at the intense level of therapy
services that can be found in an acute inpatient rehabilitation
facility. It was not felt that this therapy could have been
provided at a lesser intense level of care.
Preparing the Appeal –
ADR Cover Letter
• Example ADR Cover Letter:
 Provide Therapy Necessity:
• Functionally, at the time of admission, she was noted to be
modified independent for eating and she remained so at
discharge. Grooming was noted to be supervision and she
became modified independent at discharge. Bathing was
moderate assistance and was supervision at discharge. Upper
extremity dressing was noted to be minimum assistance on
admission, modified independent at discharge. Lower extremity
dressing was maximum assistance on admission and supervision
at discharge. Toileting was moderate assistance on admission
and minimal assistance at discharge. With respect to bowel and
bladder management, she was at a modified independent level
at admission and remained so at discharge. Transfers from the
bed to wheelchair were minimum assistance at admission and
modified independent at discharge. Toileting and tub and shower
transfers were noted to be minimum assistance at admission
and supervision on discharge. With regard to locomotion she
was noted to be maximum assistance for walking at admission
and modified independent at discharge. Stairs were noted to be
maximum assistance on admission and modified independent at
discharge.
Preparing the Appeal –
ADR Cover Letter
• Example ADR Cover Letter:
 Provide Medical Necessity:
• From a medical standpoint, she was monitored closely with
respect to her pain management. Medications were adjusted,
including adding other modalities such as Lidoderm patch and
TENS trials. She also had the addition of Neurontin to address
the neuropathic component of her pain. Overall her pain
management was improved throughout her stay. Her cardiac
status was monitored. She was maintained on her Digitek and
Isoptin and blood pressures were monitored as well. Also, she
was kept on her antihypertensives from admission. Regarding
her respiratory status, she was kept on oxygen at night. She did
have frequent documented episodes of desaturation to the mid
80’s on room air with exertion and therefore required
supplemental oxygen at discharge. Her depression was
monitored as well and she was maintained on Effexor.
Preparing the Appeal –
ADR Cover Letter
• Example ADR Cover Letter:
 Summarize Findings:
• Overall, from a medical standpoint with the close medical
management and rehabilitation nursing, she did well in that
area. It should also be noted that she remained anemic
throughout her stay with her hemoglobin both on admission and
discharge varied from 8-9 mg/dl. She was treated with iron
supplementation and Epogen. From the functional standpoint, as
can be seen above, she improved significantly throughout her
rehabilitation stay in a relatively short period of time. She was
subsequently discharged to home with her family. In my opinion,
Ms. Example was treated in the most appropriate setting for her
rehabilitation needs and it is not likely that she would have
achieved such medical improvements and stability during her
rehabilitation course without the assistance of a rehabilitation
physician and a rehabilitation nurse. In addition, without the
assistance of the multidisciplinary team, I don’t believe she
would have had such excellent functional improvements during
her stay that allowed her to return back to her home setting
within a week.
Preparing the Appeal –
ADR Cover Letter
• Example ADR Cover Letter:
 Provide Additional Resources:
• Additionally, we have provided appendices for your reference for
the tabulation of therapy minutes (Appendix A) and how our
medical records are organized (Appendix B).
• Please do not hesitate to contact me if you have any questions
or need clarification.
Preparing the Appeal –
ADR Cover Letter
• Example ADR Cover Letter: Appendix B Excerpt
 Before the tabs begin you will find the following:
• Inpatient Admission Record – contains demographic
information
• IRF- PAI (Inpatient Rehabilitation Facility - Patient
Assessment Instrument)
• Coding Summary Form
• A summary for each tab is listed below
 White Tab – Admission
• Request for Treatment & Authorization
• Advance Directives Acknowledgement Form
• Pre-admission Assessment
• Referring Hospital Therapy Notes (if available)
Preparing the Appeal –
Redetermination Request
• After initial determination = denial, write a
redetermination request
 The request should detail how the claim meets medical
necessity for the reasons sited for denial.
 Consider presenting proof on all 8 conditions of participation
Preparing the Appeal –
Redetermination Request
• Redetermination Example Letter: Reasons for Denial:
 To Whom it May Concern:
• The above referenced claim was denied at determination due to
the following four (4) reasons:
The documentation submitted did not demonstrate the
intense level of rehabilitation services were provided to the
patient.
The documentation submitted did not reflect the degree of
physician involvement, which is normally only rendered in a
hospital setting.
The documentation did not reflect the need for 24-hour
availability of a registered nurse with specialized
training/experience in rehabilitation.
The documentation submitted indicated the patient could
have achieved his improvement in a less intensive setting.
• For your review, enclosed is a complete copy of the medical
records, numbered on the lower right corner of each sheet from
Page 1 to 593. The Provider respectfully requests that all of
these documents be carefully reviewed. When the record is
reviewed in its entirety Provider’s claim is properly supported
and should be paid.
Preparing the Appeal –
Redetermination Request
• Redetermination Example Letter: Patient Summary
 Patient Summary
• In summary, Mr. X is a 92-year old gentleman who suffered a
clinical stroke that left him with an objective left facial droop
dysarthria, dysphasia and right-sided in-coordination and was
admitted to Carolinas Rehabilitation from 11/24/06 through
12/15/06. Premorbidly the patient was in his normal state of
health independent with communication cognition, mobility
transfers and activities of daily living. His case was reviewed by
our consult physiatrist and was determined to be appropriate for
inpatient rehabilitation as this is the most appropriate setting for
his recovery from his stroke. It was also determined that he
required 24 hours availability of a rehabilitation physician as
well as a rehabilitation nurse or management in light of his
dementia, hypertension, COPD and history of alcohol and
tobacco abuse.
Preparing the Appeal –
Redetermination Request
 Mr. X required and received a comprehensive interdisciplinary
stroke specialized rehabilitation program that included
rehabilitation patient therapy, occupational therapy, speech
therapy, medical social worker, therapeutic recreation
services and medical psychology services. A formal team
conference led by a physiatrist occurred on a twice weekly
basis to insure a program of care. Mr. X participated in an
intense occupational and physical therapy program that
allowed him to achieve his established goals in a reasonable
time. Unfortunately, due to a lack of family support for
ongoing assistance, the patient subsequently was discharged
on 12-15-06 to a sub-acute skilled nursing facility for
ongoing decreased level of supervision and care.
Preparing the Appeal –
Redetermination Request
• Redetermination Example Continued: Regulation Citation and Rebuttal
of Denial:
 Denial Rebuttal
• 1. The documentation submitted did demonstrate the
intense level of rehabilitation services were provided to
the patient.
• Pursuant to Medicare Benefit Policy Manual, Chapter 1,
§110.4.3, the Provider either provided and the beneficiary
received at least 15 hours of combined therapy per week or
documented that the patient had a condition which prevented
such participation in therapy. Furthermore, Medicare Benefit
Policy Manual, Chapter 1, §110.1 requires that determinations of
medical necessity for IRF services be based upon an assessment
of each patient’s individual needs and prohibits denials of
payment based on “numerical utilization screens, diagnostic
screens, diagnosis or specific treatment norms, ‘the three hour
rule,’ or any other ‘rules of thumb.’”
Preparing the Appeal –
Redetermination Request
 Mr. X required an intense level of therapy services as
evidenced by the pre-admission document that can be found
on pages 11-17. An intense level of services was ordered in
the admission orders on page 50-52. Mr. X participated in
therapy as per the grid in Appendix A. He received 1080
minutes in week 1 and 1260 in week 2 and 1260 in week 3.
This indicates that Mr. X received more than the required
amount of therapy.
Preparing the Appeal –
Redetermination Request
• Redetermination Example Continued: Regulation Citation and
Rebuttal of Denial:
 2.There was sufficient documentation to substantiate close
medical supervision by a physician with specialized training
or experience in rehabilitation.
 Pursuant to Medicare Benefit Policy Manual, Chapter 1, §110.4.1, the
Provider demonstrated that the patient required the 24-hour
availability of a physician with special training or experience in the
field of rehabilitation as evidenced by entries in the patient’s medical
record that reflect frequent, direct and medically necessary physician
involvement in the patient’s care: i.e., at least every two to three
days during the patient’s stay.
 Mr. X required the oversight of a rehabilitation physician for
management of his functional and medical needs. His medical
complications included recent stroke, hypertension, COPD, urinary
tract infection, and sleep disturbance.
 Mr. X required frequent intervention for the following diagnoses:
• Nutritional compromise – we consulted nutrition who assisted
with ensuring Mr. X had proper nutritional intake.
Preparing the Appeal –
Redetermination Request
• Urinary tract infection – we diagnosed this infection on November
27th. A UTI in an elderly person can significantly impair their
cognitive and functional condition. It was important to monitor Mr.
X closely to ensure he was able to continue to participate in his
rehabilitation program.
• Hypertension – which was a contributor to his stroke, was an issue
during his rehab stay. We monitored his pressures closely and
determined an adjustment to his Norvasc dosing was required.
Once the dose was adjusted we continued to monitor to ensure the
change was effective. We also monitored the patient’s neurological
status as he was at significant risk for a second stroke.
• Sleep disturbance – we prescribed Trazodone for Mr. X’s sleep
disturbance and monitored his response. He needed to have
adequate sleep so he could participate in the full benefit of his
therapies. Additionally we monitored the amount of time he slept
with a sleep log to ensure the treatment was effective.
• In addition to managing the medical complications detailed above, I
coordinated the plan of care for nursing and therapy.
Preparing the Appeal –
Redetermination Request
• Redetermination Example Continued: Regulation
Citation and Rebuttal of Denial:
 3. There was documentation to validate the
requirement of 24-hour availability of a registered
nurse with specialized training or experience in
rehabilitation.
• Pursuant to Medicare Benefit Policy Manual, Chapter 1, §
110.4.2 the facility demonstrated the patient required
the 24-hour availability of a registered nurse with
specialized training or experience in rehabilitation
through the comprehensive rehab nursing documentation
found in the Nursing documentation sections as well as in
the multidisciplinary team meetings.
Preparing the Appeal –
Redetermination Request
 Mr. X required the 24-hour availability of a
rehabilitation nurse to treat the following:
• Skin integrity concerns due to decreased mobility,
hemiparesis and nutritional deficits treated by nursing via
daily skin assessments, application of prescribed
medications and pressure ulcer prevention techniques.
• Safety concerns due to weakness, hemiparesis, and
cognitive deficits. Interventions included frequent
monitoring and assistance with mobility.
• Nutrition and hydration issues in light of recent
cerebrovascular accident. He was treated with
rehabilitation nursing education, nutritional consult and
prescribed medications
Preparing the Appeal –
Redetermination Request
• Knowledge deficit in the areas of nutrition, safety, medication
management, complications of diagnoses, advanced directives,
pain, patient rights and responsibilities, infection control, and
self care. Education on these items was provided during his
entire stay and evidence can be found on pages 565-567.
• Mobility and self care deficit was treated by nursing by carryover
of therapy techniques during outside of therapy. Nursing
documentation of therapy carryover can be found in the
rehabilitation nursing documentation and in the interdisciplinary
Functional Independence Measure document on pages 91-128.
• In ordering rehabilitation nursing at Carolina’s Rehabilitation it
was known that nursing would perform daily assessment and
intervention on fall risk, neurological checks, psychosocial
status, respiratory status, cardiovascular status, gastrointestinal
status, renal status, bowel and bladder status, mobility, wound
care, pain, safety and intake and output monitoring.
Assessment and intervention on these items can be found in the
daily nursing documentation.
Preparing the Appeal –
Redetermination Request
• Redetermination Example Continued: Regulation Citation and
Rebuttal of Denial:
 4. The documentation submitted indicated the patient could
not have achieved his improvement in a less intensive
setting.
 Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4
Rehabilitative care in a hospital, rather than in a SNF or on an
outpatient basis, is reasonable and necessary for a patient who
requires a more coordinated, intensive program of multiple services
than is generally found out of a hospital. A patient probably requires
a hospital level of care if they have either one or more conditions
requiring intensive and multidisciplinary rehabilitation care, or a
medical complication in addition to their primary condition, so that
the continuing availability of a physician is required to ensure safe
and effective treatment.
Preparing the Appeal –
Redetermination Request
 As can be seen from a review of the medical record, Mr. X
had significant medical comorbidities prior to and during his
rehab admission that required frequent and direct
interventions from the physiatrist and rehabilitation nurse.
Based on this and his functional needs, it was appropriate to
admit him into an acute inpatient rehabilitation facility.
When it became apparent his family would not be able to
care for him in the community and he no longer needed the
24 hour availability of a rehab physician and nurse he was
discharged to a skilled nursing facility as was appropriate.
Preparing the Appeal –
Redetermination Request
• Redetermination Example Continued: Regulation Citation and
Additional Information:
 Additional Information
 Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4.6
hospitalization after the pre-admission screening is covered only in
those cases where the pre-admission screening results in a
conclusion by the rehabilitation team that a significant practical
improvement can be expected in a reasonable period of time. It is
not necessary that there be an expectation of complete
independence in the activities of daily living, but there must be a
reasonable expectation of improvement that is of practical value to
the patient, measured against the patient’s condition at the start of
the rehabilitation program. Mr. X’s pre-admission assessment on
pages 11-17 indicated inpatient rehabilitation was the most
appropriate setting. In rehabilitation his progress from maximal to
moderate assistance with most functional activities and mobility
progressed to moderate to minimal assistance with most functional
activities (please see therapy evaluation on page 485-487 and
discharge summary on pages 483-484 for complete functional
results) was significant in that it lessened the burden of care to his
caregivers.
Preparing the Appeal –
Redetermination Request
 Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4.7 the
most realistic rehabilitation goal for most Medicare beneficiaries is
self-care or independence in the activities of daily living; i.e., selfsufficiency in bathing, ambulation, eating, dressing, homemaking,
etc., or sufficient improvement to allow a patient to live at home with
family assistance rather than in an institution. Additionally the Policy
Manual states the aim of the patient’s treatment is to achieve the
maximum level of function possible. Review of the physical therapy
and occupational therapy evaluation on pages 485-487 shows the
patient’s assessment levels as requiring physical assistance with the
majority of self care and mobility items. Page 487 of the evaluation
shows the goals established as supervision for most functional
independence measure items. Achieving this level of independence
would have enabled Mr. X to return to the community with
supervision.
Preparing the Appeal –
Redetermination Request
• Redetermination Example Continued: Conclusion:
 Conclusion
• I do not believe that Mr. X could have received this required care
at any other setting other than an acute inpatient rehabilitation
facility. The patient, in my opinion, was most appropriately
treated at an intensive rehabilitation level of care and, in my
opinion, would have more than likely had significant medical
complications and worse functional outcome if treated at a lower
level of care.
• Please also see attached Appendix A - a spreadsheet that
summarizes the amount of combined therapy the beneficiary
received and Appendix B - a guide to the structure of the
medical record.
• We respectfully request that you render a favorable decision so
that Carolinas Rehabilitation may receive Medicare payment for
the above-referenced claim. Should you need any further
information or documentation, please do not hesitate to contact
me. Thank you.
 Respectfully,
Winning Doctor, MD
Carolinas Rehabilitation
Preparing the Appeal –
Supporting Letters
• Consider letters from the referring MD and the patient
 Referring MD
• Send a letter from the attending rehab doctor
Remind them of the patient and your screening process to
validate the patient’s selection
Explain the FI’s activity in your facility and area
Let them know how and why you are proceeding with the
appeals process
Underscore the importance of maintaining access to care and
your facility’s mission
• Write the letter for the doctor and list why rehab was necessary
Preparing the Appeal –
Supporting Letters
 Patient
• Send them a letter at denial, assuring them they will not have to
pay
• Explain the FI’s activity in your facility and area
• Let them know how and why (because the denial was an error)
you are proceeding with the appeals process
• Underscore the importance of maintaining access to care and
your facility’s mission
• Ask them to write a letter saying why they needed inpatient
rehab
• Have them send you the letter so you can use in the
Redetermination, Reconsideration, and above.
Appeals Tracking
• What eRehabData tracks:
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Type of request
Dates of correspondence with the FI
Dates of responses from the FI
Reason for denial
Payment/denial amounts
• How we report it:
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Active appeals
Closed appeals
Total cases in appeal at each stage
Total dollars in dispute at each stage
Total dollars paid at each stage
Total dollars denied at each stage
Appeals Tracking System
• Data Repository
 Allows you to upload medical records for storage in
eRehabData
 Can keep records in storage for later review
 Others can access records with the proper privileges
 Assistance with appeal preparation can occur from remote
locations
Words of Wisdom
 Appeal all claims
 Track all claims
 Adhere to time frames
• Receive information from Business/Finance Office in a
timely manner
• Respond in a timely manner with the correct documents
 Review carefully all documents from the FI
 The ADRs may come in quickly and in large numbers
• Have a system to make the process flow smoothly
• Appoint a person or two to write the initial appeals to
gain proficiency. Proficiency yields efficiency.
Thanks
• Thank you to Carolinas Rehabilitation in Charlotte, NC for the
examples provided and their willingness to share with all of us
what they perfected during their experience with a Fiscal
Intermediary Probe Audit.
• Thank you to Suzanne Snyder who prepared many of these
slides for original use in the Supporting Medical Necessity
workshop sponsored by eRehabData.
Questions?