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14 answered questions
I have a question surrounding CPS cases for newborns. Has anyone found any documentation to support continued stay due to CPS hold on an infant with MCOs?
Every state is different. You can check with her state’s Child Protective Services (CPS) for more specific information. Here are some thoughts with references that may help in an appeal. I hope this helps.
If the infant is currently under Child Protective Services (CPS) hold, continued hospitalization is appropriate due to complex medical, social, and legal factors. Children in CPS custody require comprehensive evaluation and coordination of care to address physical, developmental, and psychosocial needs, as well as to ensure safe discharge planning.
The American Academy of Pediatrics (AAP) states that managed care arrangements must recognize the unique needs of children in foster care or those enduring adverse conditions, support flexible eligibility and treatment policies, and facilitate access to coordinated, multidisciplinary care teams. Hospitalization is medically necessary to ensure that all recommended specialty evaluations, social work assessments, and care coordination are completed prior to discharge, as these children are at increased risk for adverse health outcomes and require ongoing follow-up.
Discharge planning for infants in CPS custody must consider the availability and reliability of safe placement, skilled nursing coverage, and the ability of caregivers to meet medical needs. Social or resource issues in the home environment may justify continued institutional care when safe alternatives are not available. The hospital team must verify that the placement can provide adequate medical supervision and that all legal and consent requirements are met, as outlined by AAP guidelines for children in child welfare protective custody.
Additionally, managed care organizations are required to provide timely authorization for necessary inpatient and specialty services and should not impose barriers to care for federally mandated services or urgent needs. The ongoing hospital stay is essential to ensure compliance with these standards and to protect the health and safety of the infant during this period of legal and social transition. Hospitals providing care to children should review their contracts with payers regarding payment for ongoing care for a child in CPS custody.
I would argue that continued hospitalization is medically necessary for this infant under CPS hold to complete multidisciplinary evaluation, ensure safe discharge planning, and comply with legal and managed care requirements for children in protective custody.
Here are some references that may help support an appeal.
Ongoing Pediatric Health Care for the Child Who Has Been Maltreated.
Flaherty E, Legano L, Idzerda S. Pediatrics. 2019;143(4):e20190284. doi:10.1542/peds.2019-0284.https://publications.aap.org/pediatrics/article/143/4/e20190284/37179/Ongoing-Pediatric-Health-Care-for-the-Child-Who?autologincheck=redirected
What Happens After the Hospital? An Analysis of Longitudinal Care Needs in Children Treated for Child Physical Abuse.
Johnson BL, Gerzina EA, Naik-Mathuria B, et al. Journal of Pediatric Surgery. 2021;56(10):1696-1700. doi:10.1016/j.jpedsurg.2021.05.019.https://www.sciencedirect.com/science/article/abs/pii/S0022346821004280
Hospitalizations Among Children Involved in the Child Protection System: A Long-Term Birth Cohort Study From Infancy to Adulthood Using Administrative Data.
Gnanamanickam ES, Nguyen H, Armfield JM, et al. Child Abuse & Neglect. 2020;107:104518. doi:10.1016/j.chiabu.2020.104518.https://www.sciencedirect.com/science/article/abs/pii/S0145213420301733
Guiding Principles for Managed Care Arrangements for the Health of Newborns, Infants, Children, Adolescents and Young Adults.
Carlson KM, Berman SK, Price J. Pediatrics. 2022;150(2):e2022058396. doi:10.1542/peds.2022-058396.https://publications.aap.org/pediatrics/article/150/2/e2022058396/188583/Guiding-Principles-for-Managed-Care-Arrangements
Considerations in the Determination of Medical Necessity in Children: Application to Contractual Language.
Giardino AP, Hudak ML, Sood BG, Pearlman SA. Pediatrics. 2022;150(3):e2022058882. doi:10.1542/peds.2022-058882.https://publications.aap.org/pediatrics/article/150/3/e2022058882/188901/Considerations-in-the-Determination-of-Medical
Special Requirements of Electronic Health Record Systems in Pediatrics: Clinical Report.
Dufendach KR, Lehmann CU, Spooner SA. Pediatrics. 2024;154(4):e2024068509. doi:10.1542/peds.2024-068509.https://publications.aap.org/pediatrics/article/154/4/e2024068509/199440/Special-Requirements-of-Electronic-Health-Record
Our facility is beginning to see a trend where a claim is being denied for two different reasons. The claim is originally denied for medical necessity, we appeal the determination, and it is overturned. UHC then performs another review denying the DRG. Any suggestion or advice on how approach this? We are also seeing cases overturned for medical necessity and then a coding or clinical validation denial arrives.
Here are some thoughts:
- Make the CDS team aware of what is happening. Perhaps they can look to see if their intervention in any of the cases might have made a difference and use that information going forward.
- Are the clinical validation denials actually valid denials? Querying about the clinical validity of a diagnosis, though difficult to do sometimes, is an important part of the CDS’ job.
- Some hospitals have CDS’ review all discharge charts prior to billing to make sure that documentation is as strong as possible prior to billing.
- Discuss the recurring issue with UHC payer representatives and seek clarity on their criteria for both medical necessity and DRG validation. This might help you better tailor your documentation and appeals.
- Track denial patterns to identify common reasons and adjust your processes accordingly if necessary. This proactive approach might help reduce the frequency of denials and improve your overall claim approval rate.
A consulting company we worked with many years ago had us have Medicare Advantage (MA) patients sign an appointment of representative (AOR) form right from the beginning of their admission. Of course, it takes more resources to get signatures from the patient after discharge. What are the pros and cons of having the patient sign the AOR form at admission?
The whole point of having the MA patient assign you their rights of appeal is so that you can appeal on behalf of the patient. For Medicare Advantage plans, appealing on behalf of the patient allows you to go through the 5-level Medicare appeal process which is not available to the provider if the provider is contracted with the plan. When you appeal on behalf of the facility, you get the number of internal (back to the payer) appeal levels that are described in your payer-provider contract or in the payer’s provider manual.
Best practice is to have the AOR form signed by the patient on admission. Some hospitals have struggled with implementing the process because it involves changes in forms, or adding new forms to registration packets, and questions arise about why every patient needs to sign the form even though not every admission will be denied. MA plans may have their own AOR form they provide for use, however, the CMS AOR form 1696 should be accepted by MA plans. You can download the form here: CMS 1696.
When completing an Appointment of Representative form for the provider to appeal on behalf of the patient, who should be listed as the representative on the form?
Recommended practice is to designate one person at your organization as your representative and have that person’s signature on your appeal letters. You might select your physician advisor or your UM manager. Select someone who is involved and knowledgeable about your appeal methodologies. It’s common to have appeal letters signed by a representative who didn’t author the actual appeal but has oversight of the appeals process at your organization. That single person acts as the representative on the AOR as well as the signatory on the appeal letters.
I have been working on appeals at my facility and have come across this frequently: Payers deny diagnoses based on their own clinical criteria, saying the documentation doesn’t meet their definition. AHA Coding Clinic 4Q 2016 (pp. 147–149) mentions that payers may require specific criteria to establish a diagnosis. Has anyone successfully challenged this or asked Coding Clinic for clarification?
Yes, we see this as well. It is a bit sticky, for sure.
Here is ACDIS advice from the 2022 update of their “Guidelines for Achieving a Compliant Query Practice:”
“Clinical Indicator(s)
… While organizations, payers, and other entities may establish guidelines for clinical indicator(s) for a diagnosis, providers make the final determination as to what clinical indicator(s) define a diagnosis.⁴”(emphasis added)
The reference referred to is Coding Clinic 1st quarter, 2014.
We are guessing they are referring to page 16: “Coding Disputes with Payers.”
It states, “Question: Can you help with coding disputes with payers when they don’t follow Coding Clinic advice or the Official Guidelines for Coding and Reporting?
Answer: Traditionally Coding Clinic does not address coding for reimbursement. Coding Clinic’s goal is to provide advice according to the most accurate and correct coding consistent with ICD-10-CM and ICD-10-PCS principles. The official guidelines are part of the HIPAA code set standards. There are a variety of payment policies that may impact coding. Some payment policies may contradict each other or may be inconsistent with coding rules/conventions. Therefore, it is not possible to write coding guidelines that are consistent with all existing payer guidelines. (emphasis added)
The following advice is provided to help providers resolve coding disputes with payers:
- First, determine whether it is really a coding dispute and not a coverage or payment issue. Therefore, always contact the payer for clarification if the reason for the denial is unclear.
- If a payer really does have a policy that clearly conflicts with official coding rules or guidelines, every effort should be made to resolve the issue with the payer. Provide applicable coding rule/guideline to payer.
- If the payer refuses to change its policy, obtain the payer requirements in writing. If the payer refuses to provide their policy in writing, document all discussions with the payer, including dates and the names of individuals involved in the discussion. Confirm the existence of the policy with the payer’s supervisory personnel.
- Keep a permanent file of the documentation obtained regarding payer coding policies. It may be come in handy in the event of an audit.”
Payers are permitted to make their own rules. But so are hospitals. It might prove helpful to have your own hospital policies and procedures regarding certain clinical criteria to make certain diagnoses – be sure to get physician buy-in and involvement making the polices. You can send the policy along with an appeal that demonstrates how the patient met the hospital’s criteria for the diagnosis.
We also advise to get out of the payer’s internal level of appeal and get your appeal to an external reviewer, if applicable.
The biggest way to make a change, though, is with your contracts.
- What do your contracts say?
- If they agree to use the payer’s criteria, you are fighting a very steep and uphill battle.
- We suggest checking out the contracts and try to get them changed if needed.
We hope you find this helpful.
Answered by: Karla Hiravi, BSN, RN | Vice President Clinical Resources, AHDAM and PayerWatch
Karla is a registered nurse and holds a BSN from the University of Pittsburgh, Johnstown. She has over thirty years of varied experiences in healthcare, including Clinical Documentation Improvement (CDI), management of a CDI department, development of a hospital-based denial and appeal program, development of an oncology research program, nurse and physician education, appeal writing, presentations at the Administrative Law Judge (ALJ) level, and direct management of appeals at every level, up to post ALJ appeals.
She was a frequent guest speaker at the University of Pittsburgh, Johnstown for many years, and served as a preceptor for nurse practitioner and Pharm D. students while they studied medical research through the University of Pittsburgh. Karla has been with PayerWatch – AppealMasters since 2016 and continues to participate in and educate clinicians and coders about the medical appeal process.
How do I request an appeal be sent for external review for a Medicare Advantage plan? We've exhausted internal appeal levels for a medical necessity denial of inpatient hospitalization level of care. The state insurance commission told me they do not handle Medicare advantage plans. The CMS website states the payor is supposed to submit claims to IRO if denials are upheld, but I don't think this is happening.
The answer depends on whether you are contracted with the plan and how you filed your internal appeals.
- If you are contracted with the plan and you appealed on behalf of the provider (hospital), you are allowed whatever internal levels of appeal are provided in your contract and that’s all. The appeal never goes to CMS. External appeal is not available unless it is provided in your contract. The state insurance commission is not involved because Medicare and Medicare Advantage plans are under a federal program.
- If you are contracted with the plan and you appeal on behalf of the patient using the patient’s appeal rights, the MA plan must automatically forward your appeal to the IRO if the plan upheld your level 1 appeal.
- If you are not contracted with the plan and you appeal on behalf of the provider (hospital), the MA plan must automatically forward your appeal to the IRO if the plan upheld your level 1 appeal.
Answered by Denise Wilson MS, RN, RRT, Senior Vice President Intersect Healthcare + AppealMasters, President, AHDAM
We recently received a delay of service denial for a NICU baby. The baby needed a non emergent procedure. Because of the fragility of the baby, they were combining 2 procedures at once. Two specialty peds surgeons were involved as well as peds cardiac anesthesia - also complicated by needed a block of a few hours in the OR. It took 2 weeks from the time the needed procedure was identified to when the surgery was scheduled/performed. We received a delay in service denial for 7 days prior to the surgery. Is there some industry “evidence based criteria” standard they are basing this on that you are aware of?
We did not find any published standards pertaining to this situation, though keep in mind that we are not lawyers. We suggest that you check the contract with the payer and see if they define “delay in care” for nonemergent procedures. We also suggest appealing based on the facts that the procedures were non-emergent, the baby was very fragile and complicated planning needed to be accomplished to combine two procedures into one operative session, taking into account the availability of two specialized pediatric surgeons and a pediatric cardiac anesthesiologist. In addition, the OR needed blocked off for an extended period of time, which can take time unless conditions are emergent.
We suggest making a point that the baby would not have been discharged from the NICU had the procedures been done earlier (if that is indeed the case) and that the delicate condition of the baby required the procedures to be done at the optimal time for the baby, as determined by the physicians. If it’s true that no harm came to the baby as a result of the procedures being pushed out, we suggest stating that as well. If the baby was in a better condition at the time of surgery than when the payer thinks it should have been done, that would be something to put in your appeal as well.
Answered by: Karla Hiravi, BSN, RN Vice President Clinical Resources, AHDAM and PayerWatch
Should we recode CPT codes and rebill claims that were incorrectly coded and then denied?
If the payer permits that and it is within timeframe, rebilling with the correct codes is recommended.
Answered by: Karla Hiravi, BSN, RN Vice President Clinical Resources, AHDAM and PayerWatch
Our organization gets late notification denials related to insurance information not being provided at time of admission. Our company makes an attempt to check coverage, but when unsuccessful, we receive the denial for no auth due to late notification. Our leadership wants these appealed and I struggle with an approach to write these appeals. I usually explain that we have no prior insurance information in our EMR, our facility has attempted to check coverage via Waystar or Relay, and that the member did not present insurance information. Is these any other suggestions/ ideas to use for these denials? Thank you.
You are on the right track to appeal with the explanation of why the correct insurance was not identified at the time of admission. Most payers are accepting of a request for a ‘retro’ authorization in these instances as long as it’s happens occasionally and not on a regular basis.
Answered by: Denise Wilson MS, RN, RRT | Senior Vice President Intersect Healthcare + AppealMasters President, AHDAM
We are seeing an increased number of payor appeals which state "The HBV review performed is a payment integrity review, not a level of care or a medical necessity review, focused on the payment of services documented in the medical record. Facility documentation submitted and reviewed by HBV has identified outpatient services were delivered, and not acute care inpatient services. HBV is not denying the services provided, rather the review is focused on the payment of services documented in the medical record. In accordance with the application of MCG guidelines, HBV has determined that the services delivered are consistent with an outpatient or observation payment." We have tried outlining the services performed, resources required, how IP level of care were met by the MCG / IQ criteria they outline. They are still being upheld. What else can we do to argue these denials?
During the latter part of 2023, some providers have been receiving medical necessity audits from third-party auditors where the auditor labels the review a payment dispute review. a payment integrity review, a billing validation, or some other similar name. These are in reality medical necessity status (inpatient versus outpatient) reviews thinly disguised as something else. AHDAM members can read our June 2023 newsletter where we call out this activity for what it is.
If you find yourself receiving a medical necessity denial issued under the guise of a payment dispute review, you’re likely not going to find relief through appealing or complaining to the auditor or the payer alone. Additional steps you can take include filing a grievance with the CMS regional office for your area, consider taking the denials as a group to the payer’s medical director for discussion, or pursuing arbitration or mediation, depending on dispute resolution options in your contracts.
Answered by: Denise Wilson MS, RN, RRT | Senior Vice President Intersect Healthcare + AppealMasters President, AHDAM
A Medicare Advantage organization is requiring certain criteria to be met that is more than what Medicare guidelines require. I don’t understand why they continue to deny after a first level appeal has been done that explains we don’t need to adhere to their requirements that are above and beyond what traditional Medicare requires. Can you help?
Medicare Advantage organizations are not permitted to be more restrictive than traditional Medicare. I suggest you make a complaint to your regional CMS office. Do not include PHI and focus on the facts and violations. Here is a list of regional CMS offices:
Regional Offices and Contact Information
- Boston ROBO…@cms.hhs.gov
Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont - New York RONY…@cms.hhs.gov
New Jersey, New York, Puerto Rico, Virgin Islands - Philadelphia ROPH…@cms.hhs.gov
Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia - Atlanta ROAT…@cms.hhs.gov
Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee - Chicago ROCH…@cms.hhs.gov
Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin - Dallas RODA…@cms.hhs.gov
Arkansas, Louisiana, New Mexico, Oklahoma, Texas - Kansas City ROKC…@cms.hhs.gov
Iowa, Kansas, Missouri, Nebraska - Denver RODE…@cms.hhs.gov
Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming - San Francisco ROSF…@cms.hhs.gov
Arizona, California, Hawaii, Nevada, Pacific Territories - Seattle ROSEA…@cms.hhs.gov
Alaska, Idaho, Oregon, Washington
Answered by: Karla Hiravi, BSN, RN, AHDAM President and Vice President Clinical Resources, PayerWatch
Please tell me if you have a list of the time frames for different payers re how long they have to answer my appeals to their denials. I have some that I have received no answer for 2 years so officially they are not resolved. Is it the same for every payer? When can I assume they are overturned?
Unfortunately, there is not one list with the different time frames that I am aware of.
Here are some ideas that might be of help.
- Commercial Insurance: Many commercial insurers have specific timelines for responding to appeals.
- Check the individual websites for information.
- Contact payer representatives for help.
- Medicare: For Medicare, the response time for appeals can vary depending on the level of appeal.
- Check on the CMS website: https://www.cms.gov/medicare/appeals-grievances/fee-for-service to start.
- Medicaid: Medicaid response times can vary by state. For example, some states require Medicaid managed care organizations to respond to appeals within 30 days.
- State Laws: Some states have laws that set specific time frames for payers to respond to appeals.
- Provider Agreements: Always check the provider agreements or contracts you have with the payer, as these documents often specify the exact time frames for appeal responses.
- If you do not have access to these documents, ask the contracting team for assistance.
Answered by: Karla Hiravi, BSN, RN | Vice President Clinical Resources, AHDAM and PayerWatch
My hospital system is seeing an increase in denials from a multitude of payers (but mostly Humana and Aetna via third parties) where the payer has performed a clinical validation audit and found "the medical records submitted did not validate I50.00 (Acute on Chronic Diastolic (Congestive) Heart Failure). The member presented to the hospital for TAVR. It was noted the physician documented a diagnosis of acute on chronic diastolic CHF, however there was no evidence of symptoms. The specific criteria for Modified Framingham criteria was not met...." The payers are downgrading the billed DRG from 266 to 267. We are appealing these denials with the full medical record and outlining the physician's diagnosis from the records; sometimes submitting past cardiology progress notes to support the diagnosis. Can AHDAM provide any additional tips, policies or insight into these denials and how to approach them for payment?
Yes, we do!
Here is a specific reference from an article by Packer that might help support your arguments:
Packer M, Lam CS, Lund LH. Prognostic Implications of Elevated Left Ventricular End-Diastolic Pressure in Patients with Aortic Stenosis. Circulation. 2018;137(18):1868-1874.
“In patients with aortic stenosis, an LVEDP greater than 15 mmHg is a reliable marker of left ventricular dysfunction and congestion. When elevated above this threshold, it is strongly associated with worsening heart failure, increased mortality, and the need for timely intervention. Elevated LVEDP in the presence of symptomatic heart failure suggests an acute exacerbation of chronic heart failure, necessitating prompt treatment to prevent further decompensation.”
This quote helps establish the significance of an elevated LVEDP as a critical indicator of acute on chronic heart failure in patients with aortic stenosis.
Answered by: Karla Hiravi, BSN, RN | Vice President Clinical Resources, AHDAM and PayerWatch
Our facility received a denial for 10 days of service due to lack of medical necessity. The patient had stabilized and was ready for discharge. However, the discharge was delayed due to the insurer denying placement in an inpatient rehab facility. The delay in discharge was not due to our facility, but due to post discharge placement denials by the payer. Can you please advise how to appeal these? Do you have samples of verbiage to utilize for a more impactful appeal letter?
Thank you for reaching out with this important question. When appealing a denial for inpatient days that were necessary solely due to a delay in post-acute placement caused by the payer, it is critical to shift the focus of the argument. Your appeal should emphasize that:
The hospitalization was extended solely due to the payer’s failure to approve appropriate post-acute care. The patient was medically ready for discharge, but the insurer’s refusal to approve inpatient rehabilitation forced continued hospitalization.
The denial contradicts established payer responsibilities under managed care contracts and regulatory expectations. Many states, as well as Medicare Advantage regulations, recognize that a payer-caused delay in discharge does not negate the medical necessity of continued hospital care.
Industry standards recognize discharge delays due to placement issues as unavoidable, and they should not result in an unfair financial penalty to the hospital. Payers cannot deny coverage for hospital days when their own actions prevent timely discharge.
Appeal Strategy & Sample Verbiage
Subject: Appeal of Denial for Inpatient Days Due to Placement Delay
Dear [Insurer’s Representative],
We are appealing the denial of inpatient hospitalization for [Patient Name] from [Start Date] to [End Date] on the basis that these days were medically necessary due to the insurer’s failure to authorize post-acute placement in a timely manner.
The medical record clearly documents that as of [Date], the patient was stable and ready for discharge to [Intended Post-Acute Setting]. However, despite multiple requests and supporting documentation, [Insurer Name] denied coverage for this level of care, thereby delaying discharge.
Because the patient could not be safely discharged home and no alternative level of care was approved by [Insurer Name], continued inpatient hospitalization was unavoidable. Denying these days penalizes the hospital for an issue entirely within the payer’s control. This is inconsistent with the principles of fair claims adjudication and payer obligations to ensure timely discharge options for covered patients.
We request that [Insurer Name] overturn this denial immediately. Should this matter proceed to an Independent Review Organization or regulatory appeal, we will provide full documentation of the discharge attempts, insurer denials, and the impact of these delays on both the patient and hospital operations.
Please provide a written reconsideration response within [Timeframe per contract or regulations].
Sincerely,
Note that various state and federal laws (under 42 CFR primarily) could also apply.