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Ask the Expert Q&A

Question: 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?

Answer:  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

1 Boston [email protected]
Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

2 New York [email protected] 
New Jersey, New York, Puerto Rico, Virgin Islands

3 Philadelphia [email protected]
Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

4 Atlanta [email protected]
Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

5 Chicago [email protected] 
Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

6 Dallas [email protected] 
Arkansas, Louisiana, New Mexico, Oklahoma, Texas

7 Kansas City [email protected] 
Iowa, Kansas, Missouri, Nebraska

8 Denver [email protected] 
Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

9 San Francisco [email protected] 
Arizona, California, Hawaii, Nevada, Pacific Territories

10 Seattle [email protected] 
Alaska, Idaho, Oregon, Washington

Answered by: Karla Hiravi, BSN, RN, AHDAM President and Vice President Clinical Resources, PayerWatch   


Q: 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?

A: 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


Q: 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.

A: 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


Q: Should we recode CPT codes and rebill claims that were incorrectly coded and then denied?

A: 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   


Q: 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? 

A: 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   

 Q: 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.

A: The answer depends on whether you are contracted with the plan and how you filed your internal appeals.

a) 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.

b) 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.

c) 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

Q: I have been working on appeals at my facility and have come across this frequently:

Please reference AHA Coding Clinic 4th Q 2016 pgs. 147-149 which addresses that payors may require a specific clinical definition/criterion to establish a diagnosis.

We are thinking of trying to address this with Coding Clinic somehow.

Do you have any experience fighting against this particular argument or know if anyone has asked Coding Clinic for further clarification?

A: 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.

Q: 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?

A: 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.

Q: 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? 

A: 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.