THE BENEFIT NEWSLETTER

The Newsletter of the Association for Healthcare Denial and Appeal Management

JANUARY 2023

Our next webinar:

Different Payers Mean Different Appeal Strategies

(Provider email domain is required for registration approval)
Wednesday, March 1, 2023, at 2 PM Eastern Time
CEU’s for AHDAM Members Only

So often the answer to 'How do I appeal this or that?" depends on the answer to "Who is the payer, and do you have a contract?" Join us as we discuss the variability in the appeals process based on payers and payer contracts.

About the presenter:

Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch/AppealMasters, President, AHDAM

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing.

Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level. Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning healthcare denials.

Click Here to Register!

You must register with a business or provider email address.

General email accounts such as Gmail or yahoo will not be approved for attendance.

Welcome to the new AHDAM website!

New year, new website! Our new website will continue to keep our members connected with latest industry news and webinars, along with tip sheets, policies, procedures, and more. You'll find our updated site makes it easy to navigate to your favorite content. And we've made it simpler to sign-up, renew, and manage your membership. And, we will continue to roll out additional features over the next few months.

While you are logged in, please complete your profile. You’ll find the link for profile update under the Welcome on the welcome page, or you can click on the link below.

If you are a primary contact for a group membership, you also have access to your organization's profile where you can manage your team. Here's how to access:

Click here to go to your member profile.
Click on the Update My Profile underneath the welcome text.

For instructions on adding, removing and/or editing individuals from a group membership, please click here.

We’re excited about the year ahead and we hope you will be, too! If you have any questions, please contact AHDAM Headquarters at [email protected] or (410) 931-8100.

Everyone Should Comment on the CMS Proposed Rule for Changes to the Medicare Advantage Program (and we’re going to make it easy for you)

By Denise Wilson MS, RN, RRT, Senior Vice President Denial Research Group/AppealMasters, President AHDAM

A little background:

The Office of Inspector General (OIG) issued a report on Medicare Advantage Organizations (MAO) on April 27, 2022, https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf. In the report, the OIG expressed concern regarding MAOs using clinical criteria not contained in Medicare coverage rules. The OIG was also concerned that CMS guidance was not detailed enough to determine whether MAOs were allowed to employ internal clinical criteria that went beyond Medicare coverage rules.

In response, CMS issued a request for information (RFI) asking patients and providers to comment on certain aspects of the Managed Medicare program, https://www.federalregister.gov/documents/2022/08/01/2022-16463/medicare-program-request-for-information-on-medicare. Almost 4000 comments were submitted to CMS. In August 2022, AHDAM submitted a formal comment to The Centers for Medicare and Medicaid Services in response to their request for information (RFI) on the Managed Medicare program. In the comment, AHDAM made four recommendations for changes to the Managed Medicare program:

AHDAM suggested CMS require Managed Medicare plans to follow the CMS definition of inpatient regardless of contract status with the provider.
AHDAM also requested agreement with the OIG’s April 2022 report that “CMS should issue new guidance on both the appropriate use and the inappropriate use of MAO clinical criteria that are not contained in Medicare coverage rules.”
AHDAM requested third-party auditors employed by the Medicare Advantage Organizations (MAOs) be held responsible by the MAOs to follow the Medicare administrative appeals process for noncontracted providers.
and, finally, AHDAM requested CMS should clarify this statement in the Medicare Managed Care Manual - Chapter 4 – Section 10.16 Medical Necessity, Benefits and Beneficiary Protections: “if the plan approved the furnishing of a service through an advance determination of coverage, it may not deny coverage later on the basis of a lack of medical necessity[.]”

On December 27, 2022, CMS published a proposed rule CMS-4201-P in response to the RFI, https://www.federalregister.gov/documents/2022/12/27/2022-26956/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program. AHDAM encourages everyone reading this to review and respond with comments to the proposed rule. Comments are due to CMS by 5 p.m. on February 13, 2023. Comments can be submitted at https://www.regulations.gov/commenton/CMS-2022-0191-0001.

The proposed rule:

There are 12 provisions of Medicare Advantage program included in the proposed rule. The provision we are most interested in is provision “e”: Utilization Management Requirements: Clarifications of Coverage Criteria for Basic Benefits and Use of Prior Authorization. CMS summarizes it with the following 4 points:

require MA plans to follow Traditional Medicare coverage NCDs, LCDs, statutes and regulations when making medical necessity determinations,
require plans to provide a public summary of evidence that was considered during the development of the internal coverage criteria used to make medical determinations,
require that an approval granted through PA processes must be valid for the duration of a prescribed course of treatment and that plans are required to provide a minimum 90-day transition period when an enrollee who is currently undergoing treatment switches to a new MA plan, switches from Traditional Medicare to an MA plan, or is new to Medicare, and
require MA organizations to establish a committee, led by the Medical Director, that reviews utilization management, including PA, policies annually and keeps current of LCDs, NCDs, and other Traditional Medicare coverage policies.

It’s evident that the first summary item in the proposed rule addresses the first comment AHDAM made on Medicare Advantage plans in response to the RFI. That is, suggesting CMS require Managed Medicare plans to follow the CMS definition of inpatient, and issuing new guidance on both the appropriate use and the inappropriate use of MAO clinical criteria that are not contained in Medicare coverage rules.

The prevailing opinion in the denial and appeal community seems to be that CMS intends in the proposed rule for all Medicare Advantage Organizations (MAO) to follow the “2-Midnight Rule” as the definition of hospital inpatient status, but questions still remain. Although CMS dedicated a good number of pages to provision “e” in the Federal Register, nowhere did CMS clearly and unequivocally state that MAOs would be required to follow the “2-Midnight Rule” in the way Traditional Medicare honors it.

Even if CMS intends MAOs to follow the “2-Midnight Rule”, who will be responsible for enforcing their adherence? Will CMS or the OIG audit the MAOs for compliance? Will the MAO’s internal appeals process honor the rule?

The second summary statement in the proposed rule addresses AHDAM’s second comment in response to the RFI. That is, issuing new guidance on both the appropriate use and the inappropriate use of MAO clinical criteria that are not contained in Medicare coverage rules.

The CMS proposed rule that MAOs must follow NCDs, LCDs, statutes and regulations when making medical necessity determinations is not new. However, this expectation is proposed to be moved from guidance to code. The expectation will be codified meaning that it will be given greater weight in arguing for appropriate coverage and payment for services provided to MAO members. In the absence of an NCD, LCD, Medicare statute or regulation, the proposed rule would allow MAOs to establish internal coverage criteria based on current evidence or clinical literature.

CMS did not respond to AHDAM’s third comment regarding third-party auditors employed by the Medicare Advantage Organizations (MAOs) being held responsible by the MAOs to follow the Medicare administrative appeals process for noncontracted providers. Perhaps they felt that was an issue between the MAOs and their contractors and not the responsibility of CMS to address. Many noncontracted providers in the denial and appeal community have experienced a lack of appropriate administrative handling of appeals which increases the administrative burden on the provider.

CMS also did not respond to AHDAM’s fourth comment clarifying the statement in the Medicare Managed Care Manual - Chapter 4 – Section 10.16 Medical Necessity, Benefits and Beneficiary Protections: “if the plan approved the furnishing of a service through an advance determination of coverage, it may not deny coverage later on the basis of a lack of medical necessity.” Some providers have found this statement to be ignored by MAOs. Others have found success in including this statement in their appeal arguments. Either way, this single statement buried in the manual seems ambiguous and its original intent is unclear.

There is a lot of history behind this proposed rule. The fact that CMS seems to be telling providers that their intent was for MAOs to provide members Traditional Medicare benefits, and follow Traditional Medicare coverage, and inpatient status is a Medicare benefit, and the “2-Midnight Rule” is Traditional Medicare coverage leaves one wondering why now? We may never know for sure why now, but what we do know is that CMS is listening to patient and provider stories and experiences. Now is the time to continue that dialogue with CMS and comment on their proposed rule.

For your convenience, AHDAM has created a comment template for your use with placeholders for the issues we’ve addressed in this newsletter. The template can be downloaded for free at www.ahdam.org.

For more information, we invite you to watch the publicly available recorded webinars on the PayerWatch website at www.payerwatch.com:

Medicare Advantage Denials: A Call to Arms!

Medicare Advantage Denials – A Provider Call to Arms – Part 2 and Part 3

About the author

Denise Wilson has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing.

December 2022

Our next webinar: Anatomy of Successful Medical Necessity Appeals

(Provider email domain is required for registration approval)

Wednesday, January 25, 2023, at 2 PM Eastern Time

CEU’s for AHDAM Members Only

Everyone wants to know the most effective structure of a written medical necessity appeal argument. Join us as we discuss efficient and effective methods for structuring the written appeal for medical necessity inpatient and outpatient services.

About the presenter:

Denise Wilson, MS, RN, RRT

Senior Vice President, PayerWatch/AppealMasters, President, AHDAM

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing.

Click Here to Register!

You must register with a business or provider email address.

General email accounts such as Gmail or yahoo will not be approved for attendance.

2022 Year in Review

By Denise Wilson MS, RN, RRT

Senior Vice President Denial Research Group/AppealMasters

President AHDAM

2022 was another successful year for the association in growth and service to our members. AHDAM distributed weekly industry content (The Brief email) for 37 weeks this year along with 9 newsletters (The Benefit). AHDAM published 20 stories on the latest industry news on its website.

We celebrated several new milestones during the year, added advisory board members with experience outside the acute care hospital setting, participated in advocacy activities, and met the majority of our goals for 2022.

In addition to accomplishments published here, the AHDAM 2022 Annual Benefit Report will be published on our website by the end of Q1 2023.

Milestones

I am excited to announce that AHDAM gained over 100 new members in 2022! Many organizations are taking advantage of the discounted group memberships to include all of their denial and appeal management team members.

We had our largest webinar attendance of 477 attendees for our December 2022 webinar on Dispelling Widespread Misunderstandings of the 2-Midnight Rule presented by AHDAM advisory board member, attorney David Glaser of Fredrikson & Byron.

AHDAM presented 10 complimentary webinars in 2022 for members and non-members, 4 more than in 2021. One complimentary webinar was provided specifically for the local WA/ID ACDIS chapter. And 4 complimentary webinars were provided in partnership with PayerWatch. The first in a 3-webinar event on clinical validation in sepsis denials presented by AHDAM and PayerWatch saw a record 536 attendees. Webinar recordings are available on the AHDAM website at https://ahdam.org/denial-and-appeal-management-webinars/ and the PayerWatch website at https://www.payerwatch.com/webinars/ The webinar recording with the most views is the Best Practices in the Appeals Process from September of 2022.

New to the Association’s Advisory Board

AHDAM added two new Advisory Board members in 2022.

DeAnna Fling, MHA, RRT,

Revenue Cycle Educator, McKesson Pharmaceutical Solutions & Services, The Woodlands, TX.

DeAnna has 20 years in combination of clinical and revenue cycle experience in both the hospital setting and oncology medical practice. DeAnna has been writing appeals for 13 years in hospital Part A, HOPD and oncology. She has presented cases to the Administrative Law Judge and provided physicians and billing teams education based on denied services. In the current role of revenue cycle educator for USON, DeAnna provides education to insurance follow-up staff on best practices in researching payer policies on denied services and drafting appeal letters to all payers.

Rishi Garg, MD, MBA

Medical Director of Case Management/Utilization, Loyola University Medical Center, Melrose Park, IL

Dr. Rishi Garg is an Assistant Professor of Neurology at Loyola University Medical Center in Chicago. He is board certified in Neurology, Clinical Neurophysiology and holds an ABQAURP certification. He has an MBA from University of Chicago with concentrations in finance, accounting, and entrepreneurship. He has held various leadership positions including member of utilization review committee and is currently medical director over financial clearance and prior authorization.

Both DeAnna and Dr. Garg bring expertise and interest in outpatient and physician office denial and appeal management, helping AHDAM to reach its goal of expanding support and resources to members employed outside of the acute care hospital setting.

Advocacy

In August 2022, in response to The Centers for Medicare and Medicaid Services (CMS) request for information (RFI) on the Managed Medicare program, AHDAM presented a Medicare Advantage Denials: A Call to Arms webinar. Denial and appeal experts Dr. Brian Moore and Brian McGraw discussed the top issues of the Medicare Advantage program that should be brought to the immediate attention of CMS program administrators and congressional leaders. The webinar included a template developed by AHDAM for use by AHDAM members and other interested parties in responding to the CMS RFI.

In August 2022, AHDAM submitted a formal comment to The Centers for Medicare and Medicaid Services in response to their request for information on the Managed Medicare program. In the comment AHDAM made four recommendations for changes to the Managed Medicare program.

AHDAM suggested CMS require Managed Medicare plans to follow the CMS definition of inpatient regardless of contract status with the provider.
AHDAM also requested agreement with the OIG’s April 2022 report that “CMS should issue new guidance on both the appropriate use and the inappropriate use of MAO clinical criteria that are not contained in Medicare coverage rules.”
AHDAM requested third-party auditors employed by the Medicare Advantage Organizations (MAOs) be held responsible by the MAOs to follow the Medicare administrative appeals process for noncontracted providers.
And, finally, AHDAM requested CMS should clarify this statement in the Medicare Managed Care Manual – Chapter 4 – Section 10.16 Medical Necessity, Benefits and Beneficiary Protections: “if the plan approved the furnishing of a service through an advance determination of coverage, it may not deny coverage later on the basis of a lack of medical necessity[.]”

The CMS proposed rule in response to the RFI was just recently published. AHDAM will review and respond with comments to the proposed rule.

2022 Goals

AHDAM met the majority of its 2022 goals.

Increasing/maintaining membership

Memberships were increased by 100 over 2022.

Broaden offerings to incorporate outpatient, physician office, group practice denial and appeal management

Support and resources were expanded to members employed outside of the acute care hospital setting with the addition of two new advisory board members and an October webinar on total joint surgery denials and appeals.

Engage a membership management agency

A membership management company was hired by AHDAM in 2022. Clemons & Associates of Baltimore, MD began partnering with AHDAM to improve membership management and the member experience. The Clemons & Associates, Inc. (C&A) team of professionals has a combined total of over 150 years of association management experience. AHDAM is pleased and excited to have their team join ours.

Website redesign

Clemons & Associates is assisting AHDAM with our goal of redesigning the website for easier navigation and easier membership registration and membership management. A newly refreshed website will be revealed soon.

Members Forum

A members’ forum will be available as a feature of the newly refreshed website in 2023.

Plan for regional workshop in 2023

Plans are underway to develop an in-person regional workshop for the fall of 2023. The workshop will provide hands-on, interactive training in all aspects of understanding and managing denials and appeals. We invite our members to suggest specific areas of learning that you would like to see covered in a workshop. You can send suggestions to me at [email protected].

Certification

Finally, we know there is a lot of interest from the community on AHDAM developing a certification in denial and appeal management. Certification has been a goal of AHDAM since our inception. And although we were not able to make progress on the goal in 2022, certification will be a priority goal in 2023.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

The Association for Healthcare Denial and Appeal Management (AHDAM) publishes and distributes materials in The Benefit newsletters that are created by our members or invited industry subject matter experts for the benefit of all AHDAM members. AHDAM does not certify the accuracy or authority of these materials. These materials are distributed and presented as research information to be used by AHDAM members, in conjunction with other research deemed necessary, in the exercise of AHDAM members’ independent professional judgment. AHDAM claims no liability in relation to reliance on the content of these materials. The views expressed in the materials are the views of the material’s authors and do not necessarily represent the views of AHDAM. Any references are provided for informational purposes only and do not constitute endorsement of any sources.

November 2022

Our next webinar: Dispelling Widespread Misunderstandings of the 2-Midnight Rule

(Provider email domain is required for registration approval)

Thursday, December 15, 2022, at 2 PM Eastern Time

CEU’s for AHDAM Members Only

Special guest speaker, David Glaser, shareholder at Fredikson & Byron, PA, clarifies widespread misunderstanding of CMS Two-Midnight Rule. David will be covering tips for ensuring the UM team is focused purely on physician expectation, not InterQual or MCG. He will be sharing how outdated Manual provisions may cause people to wrongly conclude inpatient status is improper. His guidance will help those involved in denial and appeal management recognize why auditors are wrong when they deny an admission asserting that the patient “only required an outpatient level of care.” And, he will present the compelling legal argument that Medicare Advantage cannot ignore the 2 midnight rule.

About the presenters:

David Glaser, Attorney

Shareholder, Fredrikson & Byron

David helps clinics, hospitals, and other health care entities negotiate the maze of health care regulations, providing advice about strategy, reimbursement and compliance.

David is a shareholder in Fredrikson & Byron’s Health Law Group and co-founded its Health Care Fraud & Compliance Group. He has considerable experience in health care regulation and litigation, including voluntary disclosures, criminal and civil fraud investigations, overpayments and reimbursement disputes.

David’s goal is to explain the government’s enforcement position, and to analyze whether this position is supported by the law or represents government overreaching. David is a frequent guest on RAC Monitor’s “Monitor Mondays,” and you may read his Blog at Orthopedics Today. He has given speeches in 36 states.

Denise Wilson, MS, RN, RRT

Senior Vice President, PayerWatch/AppealMasters, President, AHDAM

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing.

Click Here to Register!

You must register with a business or provider email address.

General email accounts such as Gmail or yahoo will not be approved for attendance.

Sharing Pearls with the Next Generation of Appeal Writers

By Denise Wilson MS, RN, RRT

Senior Vice President Denial Research Group/AppealMasters

President AHDAM

I’ve been training some new appeal writers lately and have come to realize that there are some habits that are so engrained in my writing style that I can’t help but expect the same from new writers. Some habits are a stylistic choice, but others are what I would consider best practices. Today I’m sharing some of the pearls that I share with new appeal writers. Most of the pearls apply to writing medical necessity appeals but some of it can apply to other types of appeals as well.

First, let me say that finding experienced appeal writers is so much easier these days than ten or even five years ago. It’s a reflection on how the need for an appeal management industry has grown and evolved over time. I believe it’s an industry that is poised for greater growth with formal recognition, standards, and best practices which was the catalyst behind forming AHDAM. We’ll only be successful by supporting each other through sharing stories and experiences.

For best practices, one of the most important pearls I share with medical necessity appeal writers is a list of words to avoid when appealing for inpatient status. Any patient admitted to the hospital to rule out, evaluate, monitor, or watch is an automatic outpatient with observation for payers. Avoid using those words in your appeal, even if they are written in the chart. And, a note to providers: stop using them in your notes. Patients are admitted to the hospital in inpatient status for treatment of a condition that requires hospital care. If the patient is placed in a hospital bed, but the provider is still trying to determine whether they are safe for discharge home or will require ongoing care in the hospital, that’s outpatient to a payer.

Speaking of monitoring, what does ‘close monitoring’ even mean? I see this written so often in appeal letters. Patient was admitted for close monitoring. I can’t believe that it actually makes any difference to the payers how much monitoring the patient required unless we’re talking about monitoring intracranial or central venous pressures or other critical indicators. Those patients are sick enough to definitely require hospital care. I almost never use the words ‘close monitoring’ because I don’t think it adds to the argument for inpatient status. I would discuss monitoring in the appeal if it involved every hour or every 2-hour testing or intervention by healthcare providers.

Inclusion of comorbidities or complicating factors can be quite valuable in an appeal argument. I usually include every secondary diagnosis in the coding summary because it’s pretty easy in most cases to copy and paste them in one chunk into the letter. However, if you have to type them individually into the letter, I would stick with only the pertinent comorbidities. The point is, don’t make it too difficult. If it’s easy to copy and paste a whole list, go for it. If you have to type each diagnosis individually, you might want to be more selective. If you don’t have access to the coding summary, the physician’s history and physical is the next best place to find the list of comorbid conditions.

The most important reason for including comorbidities is to refute the payer’s use of screening guidelines that account for only one diagnosis, which may or may not be the principal diagnosis. So many times, the payer denies based on commercially available screening criteria of one diagnosis when the patient presented with multiple comorbid conditions that were flaring at the same time. It’s important to discuss any conditions that had an impact on or were affected by other acute conditions that were occurring. This is a very common scenario, especially in our senior population, that leads to the need for hospital care.

I also like to include any current drug abuse/dependence (cocaine, nicotine, alcohol). Drug abuse or dependence can have medical consequences and can speak to the underlying state of health of the patient. It can also bring social factors into play concerning safe discharge, risk of financial concerns for follow-up care, or concerns for healthy living conditions.

In regard to stylistic preferences, I have a few. I refer to patients by their name, Mr., Mrs., gentleman, lady, him, her, he, she, they, them. This is a holdover from the days of writing hundreds of traditional Medicare appeals that were sure to end up in front of an administrative law judge. The thought was that using a patient’s name might bring that patient more to life as a real person experiencing real suffering who deserved to have their care covered by their insurance company. And, yes, I still teach that patients suffer or experience their symptoms. They don’t complain of their symptoms or endorse their symptoms. Their symptoms are real enough and distressing enough to bring them to the hospital for relief.

About the author

Denise Wilson has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level. Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning healthcare denials.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

THE BENEFIT

The Newsletter of the Association for Healthcare Denial and Appeal Management

October 2022

Our next webinar: Dispelling Widespread Misunderstandings of the 2-Midnight Rule

(Provider email domain is required for registration approval)

Thursday, December 15, 2022, at 2 PM Eastern Time

CEU’s for AHDAM Members Only

About the presenters:

David Glaser, Attorney

Shareholder, Fredrikson & Byron

David helps clinics, hospitals, and other health care entities negotiate the maze of health care regulations, providing advice about strategy, reimbursement and compliance.

Denise Wilson, MS, RN, RRT

Senior Vice President, PayerWatch/AppealMasters, President, AHDAM

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing.

Click Here to Register!

You must register with a business or provider email address.

General email accounts such as Gmail or yahoo will not be approved for attendance.

Payer Attempts to Place Extraordinary Burden on Provider Appeals

By Denise Wilson MS, RN, RRT

Senior Vice President Denial Research Group/AppealMasters

President AHDAM

Back to Texas Medicaid. I’m pretty certain I’ve mentioned in a previous post that Texas Medicaid often makes requests in their appeal decision letters that seem trivial and completely unnecessary in the grand scheme of the appeals process. For example, they often request that the appellant/provider not attribute in the appeal letter decisions/determinations made by HMS (the Texas Medicaid Recovery Auditor) to HHSC (Health and Human Services Commission), TMHP (Texas Medicaid and Healthcare Partner), OIG (Office of Inspector General), or HHSC Medical and UR Appeals, or any other program or entity. Texas Medicaid states in a “Tips for Submitting a RAC Appeal Letter” document on their website[1] that “it is incorrect to reference “your decision” or “your letter” when addressing HHSC Medical and UR Appeals, because HHSC Medical and UR Appeals did not make the decision or issue the [RAC Review Results] letter.” I can’t fathom how following or not following this directive has any impact on Texas Medicaid’s ability to adjudicate an appeal.

Other tips are also included, some of which are actually beneficial to the appeal writer. It makes me wonder whether we have been making auditor/payer appeal reviews too easy. “Make it easy for the reviewer by incorporating a roadmap in your appeal so that you drive the reviewer to a decision in your favor” is a mantra I have taught for many years. This means supporting the medical necessity by explaining the meaning behind signs, symptoms, tests, decision-making, concerns for risks of adverse events or deterioration of the patient’s condition. Don’t just regurgitate what’s in the record – explain its meaning. The roadmap also includes numbering the pages in the medical record and referring to those pages in the appeal so the reviewer can easily find the documentation that supports the medical necessity of the services provided. Don’t make the reviewer go hunting for it in the record. So, it was interesting to find this statement in their document, “Providers should cite documentation contained in the medical record and explain how it supports medical necessity and/or complies with Texas Medicaid policy.” And “If the submitted medical record was page numbered, inclusion of the page number is helpful. And these statements, “The physician’s documentation of patient condition and medical decision making is particularly important. A simple restating of the clinical facts of the case does not explain why the decision [to deny coverage/payment] was incorrect.”

It’s not often that a payer will give you such insight into what they expect in an appeal letter. What’s interesting is that much of what they recommend are practices that those of us who have been in the appeal writing business have been practicing and espousing all along. So, at least they are on the right track in some of their recommendations.

But I’m not letting them off the hook just yet. Texas Medicaid has issued a 3-page RAC Appeal Information Request Form that states, “This form MUST be completed and submitted with each Appeal Request”. The form requires the completion of 13 standard questions and 9 conditional questions relevant to the circumstances of the case. The form states, “Any item marked “No” will result in the Appeal Request being deemed invalid/incomplete.” Page 3 of the form includes a table to be completed to identify the location of required documentation within medical record. The location of up to 27 required documents, in fact, can be identified in the table. I agree to making it easy for the reviewer to find the supporting documentation, but generally that roadmap is included in the body of a well-written appeal letter.

It’s one thing to suggest appeal submission practices that help the payer review appeals in a more complete and efficient manner. It’s another thing to require that submitters complete extensive forms that include confirmation of processes that reflects the work the payer reviewer should be doing. For example, the submitter is asked to affirm the Appeal Request letter provides a clinical rationale for medical necessity of the claim as originally billed, beyond stating clinical data without explanation. Which brings up another point. So many decision letters from payers in general seem to ignore any clinical argument with explanation made in the appeal, and just rubber stamp the original denial, that this statement seems to be a bit of an anomaly in the appeal world.

Finally, one of the biggest causes for concern is the statement on the form that reads, “The purpose of this form is to assist providers in identifying claims that do not merit an appeal.” There’s something not right about a payer attempting to teach providers how to write an appeal. But even worse is a payer suggesting that they can assist providers with determining which denials should not be appealed.

[1] https://www.hhs.texas.gov/sites/default/files/documents/pa-03c-tips-submitting-rac-appeal.pdf

About the author

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

THE BENEFIT

The Newsletter of the Association for Healthcare Denial and Appeal Management

August 2022

Our next webinar: Best Practices in the Appeals Process

Wednesday, September 21, 2022, at 2 PM Eastern Time

CEU’s for AHDAM Members Only

Successfully overturning denials goes beyond writing a great appeal. Appeal specialists must employ best practices at every level of both the internal and external appeals process starting with peer-to-peer. Many AHDAM members are asking how best to manage various levels of appeal from a process as well as an appeal argument standpoint. In this session we will present best practices for government and commercial payers’ appeal processes.

About the presenters:

Kendall Smith, MD

Chief Physician Advisor, PayerWatch/AppealMasters

Dr. Kendall Smith is a Senior Fellow in Hospital Medicine (SFHM) and currently acts as Chief Physician Advisor for AppealMasters, a leading appeal educator and appeal services firm for hospitals and health systems. He’s been deeply involved in denial and appeals management throughout his hospitalist career, working collaboratively with UR/Case Management departments as well as Managed Care and Hospital C-Suite executives.

His familiarity with managed care denials led him to design and implement a number of CDI programs, including those at the Cleveland Clinic in Florida and the MedStar Washington Hospital Center. He has served as a physician leader on hospital revenue cycle management teams while also serving as the Physician Advisor for Clinical Resource Management. Dr. Smith is also an AHIMA ICD-CM/PCS approved trainer/ambassador.

Denise Wilson, MS, RN, RRT

Senior Vice President, PayerWatch/AppealMasters, President, AHDAM

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing.

Click Here to Register!

You must register with a business or provider email address.

General email accounts such as Gmail or yahoo will not be approved for attendance.

AHDAM’s Comments to CMS on Medicare Advantage

The Association for Healthcare Denial and Appeal Management

8600 LaSalle Rd, Suite 625

Towson, MD 21286

August 29, 2022

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-4203-NC

P.O. Box 8013

Baltimore, MD 21244-8013

The Honorable Chiquita Brooks-LaSure

Administrator

Centers for Medicare and Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244

Re: File code CMS-4203-NC

Dear Administrator Brooks-LaSure:

The Association for Healthcare Denial and Appeal Management (AHDAM) is pleased to submit its comment on file code CMS-4203-NC as requested by the Centers for Medicare and Medicaid Services (CMS), which is seeking input from the public regarding various aspects of the Medicare Advantage program.

AHDAM is the nation’s only association dedicated to healthcare denial and appeal management. AHDAM was created in 2020, with financial support of PayerWatch, Inc.,[1] in order to support and promote professionals working in the field of healthcare insurance denial and appeal management. This important work is being accomplished through education and collaboration. Our vision is to create an even playing field where patients and healthcare providers are successful in persuading medical insurers to make proper payment decisions.

AHDAM has attracted over 350 members in its short tenure and continues to experience growth in membership. AHDAM has educated thousands of professionals in best practices for managing denials and appeals from all payers including managed Medicare.

On behalf of hospitals and health systems, AHDAM is pleased that CMS is requesting feedback on ways to strengthen Medicare Advantage (MA) and create more opportunities for stakeholders to engage with CMS. AHDAM welcomes this opportunity to provide feedback to CMS on observed MA plan behaviors. We are especially interested in submitting comments on sections B.10 and B.11 of the Request for Information regarding coverage and care for Medicare-eligible individuals and the utilization management techniques employed by MA plans.

In regard to inpatient status prior authorizations, MA plans often state in their provider manuals that they adhere to CMS guidance,[2] going so far as to quote the CMS definition of an “inpatient.”[3] However, in practice, when reviewing medical documentation during the utilization management process, MA plans almost universally employ a commercially-available screening tool to determine hospitalization status for patients occupying a hospital bed. MA plans define inpatient status using the CMS definition but adjudicate claims using screening tools that are not recognized or endorsed by CMS, and do not conform to the CMS definition of an inpatient.

CMS should require MA plans to follow the CMS definition of inpatient status following the 2-midnight rule regardless of contract status with the provider. So many beneficiaries covered by MA plans would be granted inpatient status under traditional Medicare but are denied that status under the MA plans. As such, these beneficiaries lose their discharge appeal rights as well as skilled nursing facility benefits. The extended prior authorization process employed by MAOs for access to inpatient rehabilitation services or long-term acute care settings, extends hospital stays by days, while the patient misses out on receiving appropriate services for recovery.

AHDAM finds it especially concerning that CMS requires MA plans to follow national and local coverage determinations[4] yet also allows the plans to be more restrictive in their coverage requirements. The fact that the OIG in their April 2022 report[5] concluded that “CMS guidance is not sufficiently detailed to determine whether MAOs may deny authorization based on internal MAO clinical criteria that go beyond Medicare coverage rules” is alarming and indicates an area that must be rectified by CMS immediately. AHDAM agrees with the OIG recommendation that “CMS should issue new guidance on both the appropriate use and the inappropriate use of MAO clinical criteria that are not contained in Medicare coverage rules.”

AHDAM is aware of non-contracted MA plans that have failed to automatically forward provider appeals to the Independent Review Entity (IRE) following the non-PAR process, despite the September 2020 memo to MAOs from CMS[6] reminding them of provider access to the Medicare administrative appeals process. This creates an administrative burden on providers who then have to follow up with the plan to determine if the appeal was automatically forwarded as required by regulation.[7] Third-party auditors employed by the MAOs should be held responsible by the MAOs to follow the Medicare administrative appeals process for non-contracted providers without requesting additional appeal levels with the auditor or shortening the timeframes for appeal.

Because the process of the automatic forwarding to the IRE is blind to the appellant requesting the reconsideration, and thus cannot be policed by the appellant, CMS should require the forwarding agency notify the parties to the appeal when the case is automatically forwarded to the IRE. CMS should also set consequences for the MA plans for not automatically forwarding the appeal to the IRE within specified timeframes.

Finally, CMS should clarify this statement in the Medicare Managed Care Manual – Chapter 4 – Section 10.16 Medical Necessity, Benefits and Beneficiary Protections: “if the plan approved the furnishing of a service through an advance determination of coverage, it may not deny coverage later on the basis of a lack of medical necessity[.]”[8] This is a singular statement within a short paragraph regarding medical necessity. The term “advance determination” first appears in the CMS manual in 2010 and describes the process currently better known as prior authorization for services. It is not uncommon for MAOs to authorize care through prior authorization and then retroactively deny coverage of the care. There may be instances where prior authorization was granted for a service or care that ultimately veers significantly from the service or care that was authorized. In those instances, it is understandable that the coverage might be denied on retrospective audit. However, if services provided were in complete or significantly comparable agreement with the pre-authorized services, retrospective denial should not be allowed.

AHDAM appreciates the opportunity to comment on these aspects of the Medicare Advantage program, to strengthen it and make it more responsive to the healthcare needs of patients.

Sincerely,

Denise Wilson, MS, RN, RRT

President, Association for Healthcare Denial and Appeal Management

[1] Through their AppealMasters division, PayerWatch offers clinical appeal consulting and services to help providers protect their revenue from untoward medical necessity, coding, and clinical validation audits and denials.

[2] UnitedHealthcare® Hospital Services (Inpatient and Outpatient), Policy Number: MCS046.03, Approval Date: August 17, 2021, pp. 1-2; https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/hospital-services-inpatient-outpatient.pdf

[3] Medicare Benefit Policy Manual, Chapter 1 – Inpatient Hospital Services Covered Under Part A, 10 – Covered Inpatient Hospital Services Covered Under Part A, Effective: 01-01-16

[4] Medicare Managed Care Manual, Chapter 4 – Benefits and Beneficiary Protections, 90 – National and Local Coverage Determinations, 90.1 – Overview; https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf

[5] Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise

Concerns About Beneficiary Access to Medically Necessary Care, OEI-09-18-00260, Conclusion and Recommendations, p. 20; https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf

[6] Department of Health and Human Services, & Mulcahy, J., Non-Contract Provider Access to Medicare Administrative Appeals Process1–2 (2020). Baltimore, MD; CMS.

[7] The Federal Register. Federal Register: Request Access. (2022). Retrieved August 28, 2022, from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-M/section-422.590

[8] Medicare Managed Care Manual, Chapter 4 – Benefits and Beneficiary Protections, 10.16 – Medical Necessity; https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

THE BENEFIT

The Newsletter of the Association for Healthcare Denial and Appeal Management

July 2022

Our next webinar: Best Practices in the Appeals Process

Wednesday, September 21, 2022, at 2 PM Eastern Time

CEU’s for AHDAM Members Only

About the presenters:

Kendall Smith, MD

Chief Physician Advisor, PayerWatch/AppealMasters

Denise Wilson, MS, RN, RRT

Senior Vice President, PayerWatch/AppealMasters, President, AHDAM

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing.

Click Here to Register!

You must register with a business or provider email address.

General email accounts such as Gmail or yahoo will not be approved for attendance.

CMS Seeks Public Feedback to Improve Medicare Advantage

By Denise Wilson MS, RN, RRT

Senior Vice President PayerWatch/AppealMasters

President AHDAM

The news coming out of the Centers for Medicare and Medicaid Services (CMS) has been abundant over the past few weeks. In case you missed it, here’s what’s happening.

CMS Seeks Public Feedback to Improve Medicare Advantage

The Centers for Medicare & Medicaid Services (CMS) released a Request for Information seeking public comment on the Medicare Advantage program. Here is your opportunity to sound off the CMS regarding the Medicare Advantage program.

Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare stated in a news release that there is a “huge opportunity for partnership with as many stakeholders as possible” to ensure equity, access, quality, and affordability for the Medicare population who select Medicare Advantage plans for coverage. Read the news release here.

You have until 8/31/2022 to submit comments here.

AHDAM encourages everyone to submit insightful comment to CMS in an effort to inform CMS in their Medicare Advantage policy development and implementation process. Of particular interest to the provider community regarding utilization management is feedback on Coverage and Care, sections B.10 and B.11.

How do MA plans use utilization management techniques, such as prior authorization? What approaches do MA plans use to exempt certain clinicians or items and services from prior authorization requirements? What steps could CMS take to ensure utilization management does not adversely affect enrollees’ access to medically necessary care? https://www.federalregister.gov/d/2022-16463/p-47
What data, whether currently collected by CMS or not, may be most meaningful for enrollees, clinicians, and/or MA plans regarding the applications of specific prior authorization and utilization management techniques? How could MA plans align on data for prior authorization and other utilization management techniques to reduce provider burden and increase efficiency? https://www.federalregister.gov/d/2022-16463/p-48

Appeal when a hospital changes your status from an inpatient to an outpatient with observation services

Earlier this year, the US Court of Appeals for the Second Circuit issued a decision on Barrows v. Becerra, a class action suit filed by Medicare Part A beneficiaries who claimed they were denied their due process rights because there was no administrative review process for the reclassification of their hospital admission status from inpatient to outpatients receiving observation services. The appeals court affirmed a district court finding that the plaintiffs’ due process rights were violated when the utilization review committee changed their status from inpatient to outpatient with observation services without a process for the beneficiary to appeal that decision.

CMS has announced a ‘Coming Soon’ process for beneficiary appeals. The process has yet to be defined by CMS, but a few qualifying factors have already been published. From Medicare.gov, How do I file an appeal:

“You’ll have the right to file an appeal when a hospital changes your status from an inpatient to an outpatient, if you meet all of these requirements:

You were admitted to the hospital as an inpatient on or after January 1, 2009.
The hospital changed your status from “inpatient” to “outpatient” and after the status change you were an outpatient getting observation services.
You got a Medicare Outpatient Observation Notice (MOON) or a Medicare Summary Notice (MSN) telling you that observation services aren’t covered under Part A (Hospital Insurance).

And you ALSO meet 1 of these 2 requirements:

You weren’t enrolled in Part B (Medical Insurance) coverage when you were hospitalized, OR
You had Part B coverage when you were hospitalized, and you:

Stayed at the hospital for 3 or more days in a row, but were not an inpatient for 3 days, AND
Were admitted to a skilled nursing facility during the 30 days after your hospital stay (or, it’s been less than 30 days since your hospital stay).”

No word yet on how a successful appeal may impact the payment the hospital may have already received on the claim.

CMS hospital IPPS final rule for FY 2023 raises Medicare payment rates for acute care hospitals

CMS issued the fiscal year (FY) 2023 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) rule on August 1, 2022. The rule raises Medicare payment rates for acute care hospitals for admissions for FY 2023 as described below.

“For acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record users, the final rule will result in an increase in operating payment rates of 4.3%. This reflects a FY 2023 projected hospital market basket update of 4.1%, reduced by a statutorily required productivity adjustment of a 0.3 percentage point and plus a 0.5 percentage point adjustment required by statute. This is the highest market basket update in the last 25 years and is primarily due to higher expected growth in compensation prices for hospital workers.”

AHA Executive Vice President Stacy Hughes said in a statement, “We are pleased that CMS will provide hospitals and health systems with increased inpatient payments next year, rather than a cut as proposed, allowing them to better provide care for their patients and communities. That said, this update still falls short of what hospitals and health systems need to continue to overcome the many challenges that threaten their ability to care for patients and provide essential services for their communities.”

About the author

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

THE BENEFIT

The Newsletter of the Association for Healthcare Denial and Appeal Management

June 2022

Our next webinar: Legal Arguments for Clinical Appeals

Wednesday, July 22, 2022, at 2 PM Eastern Time

CEU’s for AHDAM Members Only

Writing a great clinical argument for medically necessary services is no longer enough to win appeals. Appeal specialists must employ all entitled rights of appeal and that includes understanding and incorporating legal arguments. In this session we will present legal arguments that any clinician can understand and that apply to the most common situations encountered in denials, such as Emergency Services and EMTALA, authorization, experimental or investigational, and others.

Learning Outcomes: At the conclusion of the webinar, the learner will be able to insert basic legal arguments into an appeal letter, incorporating the correct legal argument for the specific situation. The learner will be able to:

Describe the purpose of including legal arguments in clinical appeals
Identify the agency in their state that sets legal regulations for medical insurance
Match up one legal argument with the appropriate circumstances for use

About the presenter:

Bill Haynes, Esq.

Managing Attorney, PayerWatch

Bill is a member in good standing of the Maryland Bar, a member of The Association for Healthcare Denial and Appeal Management, and a member of the American Health Law Association. Bill has experience in healthcare law, including managed care contract analysis, payer-provider arbitrations, and the independent review processes. Bill personally manages a team of attorneys who do legal research, answer legal questions, and draft language for Medicare, Managed Medicare, Medicaid, and Commercial appeal cases, independent reviews, and arbitrations.

Click Here to Register!

You must register with a business or provider email address.

General email accounts such as Gmail or yahoo will not be approved for attendance.

Assessing a Denial for the Opportunity for Overturn

By Denise Wilson MS, RN, RRT

Senior Vice President PayerWatch/AppealMasters

President AHDAM

Several years ago, I was complaining about some denied hospital admission stays that I knew had no chance of successful overturn on appeal. My CEO asked me how I knew that. Well, after many years of writing appeals while studying the insurance and medical industries and their definitions of medical necessity, I had a pretty good sense of which denied cases would get overturned. I suspect anyone who has been writing appeals for a good amount of time understands exactly what I mean and possesses that same good sense.

It was only when the CEO asked me to write out my process of determining the opportunity for overturn that I realized that I had never put my thoughts to paper before. I thought my sense of doomed cases was more instinctual than anything. Turns out, when I put my thoughts to paper, a structured decision-making process emerged.

That exercise of putting thought to paper resulted in the development of an appealability scoring tool. The tool is used to gauge the strength of the documentation supporting the medical necessity of the services provided. The tool assigns a score to the denied case. The higher the score, the greater the opportunity for overturning the denial.

The purpose of the tool is to help the provider separate the wheat from the chaff so to speak. Identifying stronger cases allows the provider to focus valuable resources toward denials that are more likely to be overturned. The cases that are assigned the lowest scores provide a learning opportunity and basis for process improvement. The power of the tool comes from its use as the common denominator in comparisons that expose trends in appeal success and payer behavior.

I started by creating a tool for level of care denials. Once that tool was refined and working as expected, a tool for clinical validation and coding denials was developed. The tool was created by defining the documentation and patient presentation that would support an inpatient admission. For example, a clear inpatient order, titration of a vasoactive drip, or an inpatient-only procedure might be criteria that supports an inpatient admission. A medical record that met that definition would score a “5” on the 5-point scale. Definitions were created for 1 through 4 score ratings with the 1 rating indicating a case that we know just won’t get overturned on appeal.

Now, a very important point in developing a scoring tool is the concept of what should get paid by a reasonable payer, not what will get overturned on appeal by any particular payer. Big difference. You want the tool to be payer agnostic. If you don’t make the tool payer agnostic, then you lose the power of the tool as a common denominator to expose payer behaviors. Medical necessity is medical necessity regardless of the payer. Yes, traditional Medicare defines inpatient admission slightly differently from other payers, and yes, your tool should account for that. In fact, a tool for traditional Medicare and one that is used for all other payers makes perfect sense.

So, how does the tool expose payer behaviors? Compare the number of overturns you receive for the score “5” cases (the slam dunks that should have been paid) among your payers. Are your payers overturning the score “5” cases regularly? Or are they continuing to uphold their denials through all levels of internal appeal? Your score “5” cases that are never or rarely overturned are ripe for discussion at your joint operating meetings, discussion with the payer’s medical director, or support for complaint to your state insurance commission.

So, you can see that a simple scoring tool can provide very powerful information and support for your denial mitigation units. And the idea seems to be catching on as I hear more and more about providers creating and implementing their own simple tools. I would love to hear success stories or other ways you have employed the power of the tool to improve the efficiency or effectiveness of your team. You can email me at [email protected].

About the author

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

THE BENEFIT

The Newsletter of the Association for Healthcare Denial and Appeal Management

May 2022

Our next webinar: Fighting Readmission Denials

Wednesday, June 22nd, 2022, at 2 PM Eastern Time

CEU’s for AHDAM Members Only

Medicare’s Hospital Readmissions Reduction Program (HRRP) is approaching its 10th birthday. That has provided commercial and managed care plans plenty of time to follow suit and create their own version of a readmission review program with associated penalties. Join us as we discuss the various readmission reduction programs and successful strategies for overturning the resulting denials.

Learning Outcomes: At the conclusion of the webinar, the learner will be able to write a persuasive argument focused on defending the medical necessity of the patient’s readmission. The learner will be able to:

Identify at least three of the conditions included in the Hospital Readmission Reduction Program from the Centers for Medicare and Medicaid Services.
Identify one circumstance when a readmission may have been appropriate.
Identify one method of defending appropriate readmissions through the appeals process.

About the presenter:

Denise Wilson, MS, RN, RRT

Senior Vice President Intersect Healthcare | AppealMasters

President AHDAM

Denise serves as the Senior Vice President at Denial Research Group – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise is a Registered Respiratory Therapist, Registered Nurse, and holds a master’s degree in Management Information Systems from the University of Illinois, Springfield. Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.

Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials. Denise’s special area of expertise is in writing and producing successful appeals.

Click Here to Register!

You must register with a business or provider email address.

General email accounts such as Gmail or yahoo will not be approved for attendance.

What Do You Need to Know About Contact From a Government Agent?

By David Glaser, Esq., Fredrikson & Byron

It’s Thursday night and you or a member of your staff hear a knock on the door. There is a Crown Victoria (or its modern hybrid equivalent) in the driveway and a man or woman with short hair at the door. What should happen? Do you answer the door? Do you hide in a closet? Even a well-prepared person may panic when a person with a gun and a badge asks for them, but without preparation, a good result is even more unlikely. Here are some basic principles everyone should know about responding to an inquiry from a government investigator:

It is worth verifying the identity of the person. Ask to see ID and a badge. If the contact is by phone, be very, very skeptical. Agents rarely call people. To verify the identity of the caller, ask for their name, agency and number. Then, rather than calling back at the number that the person offers you, or the number on caller I.D, both of which can be easily fabricated, Google the government agency and ask for the person at the main switchboard. I have had three occasions where people purporting to be “agents” contacted clients trying to gather information. There is a relatively common scam where someone pretending to be a government agent attempts to extort money. Genuine government agents both understand and appreciate your attempt to verify their identity.
Understand that the investigator has the right to contact any employee unless the investigator knows that the employee is represented by a lawyer. Be polite. You don’t have to talk, but there is nothing to be gained by being rude.
Individuals have the right to choose whether or not to speak with the government investigator. Employees have every right either to agree to speak or to refuse to speak with the investigator.
Regardless of the decision, anyone contacted by a government investigator can and should notify the organization’s Compliance Officer. Sometimes agents will say that they would “appreciate it” if the contact is treated as confidential. But that is a request, not an order. With the narrow exceptions of terrorism investigations or certain financial crimes, neither of which are going to apply in a health care investigation, a government agent cannot prevent people from talking about the interaction.
With one exception, the government investigator does not have the right to insist upon an interview right then and there, and it is improper for him or her to pressure you in an attempt to obtain an interview. (The only exception is that some state licensing Boards can require individuals to agree to an interview. However, there is still generally time to consult with legal counsel before agreeing to any interview.) Any pressure should be ignored. You have the right to decide whether or not to submit to an interview. When someone feels that they are being pressured improperly, notify the organization’s Compliance Officer with the details. If you are contacted by the government, ask your employer to obtain counsel for you. In most cases your organization will both arrange and pay for legal counsel to assist. In many states the law requires it.
If you decide to refuse an interview, you should politely but firmly decline the investigator’s request. You should also ask for the investigator’s business card.
Since you are not required to submit to an interview, if you decide that you are willing to submit to one, you have the right to insist upon any precondition you desire. For example, you may require that the interview be conducted only in the presence of legal counsel. You may also choose a time and location that is convenient.
Employees often ask what they should do. They may wonder what is in their best interest and what is best for the organization. The answer should be determined on a case-by-case basis with legal counsel. If you are willing to be interviewed, it is highly advisable to have legal counsel present.
Under all circumstances, remember that you must TELL THE TRUTH to government agents. Failure to do is usually, in and of itself, a violation of the law.
DO NOT DESTROY ANY DOCUMENTS OR ATTEMPT TO HIDE EVIDENCE. Destroying evidence is a crime. While you may believe that you are helping your organization or protecting yourself, it will cause considerable damage to the reputation of everyone involved.

If you would like a free trifold card these rights and responsibilities, please send an email to [email protected] with “Agent Card” in the subject line.

About the author

David Glaser, Esq., helps clinics, hospitals, and other health care entities negotiate the maze of health care regulations, providing advice about strategy, reimbursement and compliance. David is a shareholder in Fredrikson & Byron’s Health Care Group and co-founded its Health Care Fraud & Compliance Group. He has considerable experience in health care regulation and litigation, including voluntary disclosures, criminal and civil fraud investigations, overpayments and reimbursement disputes.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

THE BENEFIT

The Newsletter of the Association for Healthcare Denial and Appeal Management

April 2022

Our next webinar: SEAL Training – The Simple Effective Appeal Letter

Wednesday, May 18th, 2022, at 2 PM Eastern Time

Presenter: Denise Wilson MS, RN, RRT, Senior Vice President Denial Research Group/AppealMasters, President of AHDAM

Summary: AHDAM has received many requests recently to present the format of a successful appeal letter. You asked, we are going to answer! This webinar is not just for the beginning appeal writer. Besides discussing appeal letter format, we will also be discussing regulatory arguments and pushback on payer denial rationale. Don’t miss it!

Click here to register!

Denial Issue or Root Cause?

By Denise Wilson MS, RN, RRT

Senior Vice President Denial Research Group/AppealMasters

President AHDAM

Successful denial and appeal management occurs when we all speak the same language. As with any craft, inside or outside of the medical field, names are applied to items, actions, and tools used to do work. There are two names in denial and appeal management that are often used interchangeably, but should not be, in my opinion. I’m talking about issue and root cause.

As the appeal advances through the appeals process the appeal specialist will attach tags to the case as part of the processing. Tags are data elements that help classify appeals in ways that allow the appeal specialist to identify patterns. Those patterns provide information useful for successful appeals and denial prevention. Some of the tags come from established nomenclature associated with the claim or the remittance advice, such as the type of bill or claim adjustment reason codes. Other tags, such as issue and root cause, are applied to a case only after review of relevant documents.

Issue

The issue tag describes the denial reason as identified by the payer. The word issue is commonly used in the industry, likely because the Medicare Recovery Audit Contractors (RAC) and other auditors identify their audits with an assigned issue. Audit issue or denial issue can be shortened to just issue. Every denial/appeal case should be assigned an issue for reporting purposes and pattern discovery.

An issue list with definitions should be created for use by appeal specialists so we are all speaking the same language. Start by creating issue categories such as medical necessity, coding, clinical validation, or technical. Then create the list of issues. Best practice is to keep the name of the issue just specific enough to capture the uniqueness of the denial.

Medical necessity as an issue actually speaks to at least two different types of denials. Medical necessity is very often used to mean the level of care was denied by the payer. But it also can mean the medical necessity of the service or procedure was denied, but the level of care was appropriate. So, medical necessity as an issue category is fine, but it is not specific enough to be used as an issue name.

You also don’t want to make the issue too specific by including information that is already captured in other data fields of your denial tracking system. For example, there is no need to create an issue named Medicare Level of Care when the payer is already identified through another data field. An issue that is too specific complicates the reporting process.

Root Cause

A root cause is “a factor which by removal would prevent the occurrence of the adverse event, other factors that affect the outcome should not be considered as root causes”.[1] I often describe root cause as the internal process failure that caused the denial to occur. Internal defines the root cause as being caused by the provider, not the payer.

A root cause is only determined after review of the denial rationale, the medical record, coding or clinical validation documents including queries, case management notes, payer contracts, billing rules, and other documents that form the claim submission process. A root cause list with definitions should be created for use by appeal specialists. The root cause should be unique enough to capture the occurrence without being overly specific.

No authorization is a good example of a root cause that is not specific enough. No authorization could mean there was no attempt at obtaining authorization for the services. No authorization could mean that authorization was attempted but denied by the payer. No authorization could mean that authorization was obtained, but the authorization number was left off the claim. If there was no attempt at authorization or the authorization number was left off the claim, those can be root causes because they represent an occurrence (something performed or not performed by the provider) that caused an adverse event (the denial).

If authorization was attempted but denied by the payer, the root cause will require further investigation. The payer may have denied authorization because adequate documentation was not sent by the provider (points to a root cause). Root cause should be specific enough to identify the failure point in the process that can be addressed through a process improvement plan.

What about claim submission where the provider did nothing wrong, but the claim denied anyway? This happens most often with audits of medical necessity, coding, and clinical validation which rely on payer auditors reviewing the record and determining whether they agree with the supporting documentation and coding of the claim. When the provider believes the medical necessity and coding of the claim is adequately supported by the documentation, but the payer disagrees, is there a root cause? I would argue there is not because the provider did not suffer a process failure that caused the denial to rightfully occur.

If after review the provider believes the claim was inappropriately denied, then there is no root cause. Every denial/appeal case should be evaluated for a root cause, but not every case will require a root cause tag. Still, the case should be tagged in some way that indicates there was no root cause found. In other words, the payer was wrong in denying the claim.

I want to be clear here that identifying a root cause (internal process failure) doesn’t mean you have to accept the payer’s decision. Even if the provider made an error in claim submission or provided documentation that was not as strong as it could have been, a denial can still be appealed in most cases.

Here are some examples of issues and root causes.

Issue List

Level of Care
Medical Necessity of Procedure/Service
Coding – Diagnosis
Coding – Procedure
Clinical Validation

Root Cause List

No Attempt at Authorization
No Documentation of Coded Procedure
Incorrect Coding of Diagnosis
Incorrect Coding of Procedure
Lack of Clinical Indicators to Support the Diagnosis

Be thoughtful in how you create your issue and root cause lists. Keep in mind the differences between the two. Issue is the result of payer actions. Root cause is the result of provider actions. Clearly define the issues and root causes so that your team is speaking the same language.

About the author

Denise Wilson has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

[1] Root cause analysis (RCA) for beginners: Root Cause Analysis Tools. SixSigma.us. (2021, November 26). Retrieved April 29, 2022, from https://www.6sigma.us/etc/root-cause-analysis-for-beginners/

THE BENEFIT

The Newsletter of the Association for Healthcare Denial and Appeal Management

February 2022

Our next webinar: Taking Action on Winnable Denials

Wednesday, March 30th, 2022, at 2 PM Eastern Time

Presenters: Denise Wilson MS, RN, RRT, Senior Vice President Denial Research Group/AppealMasters, President of AHDAM, Dr. Kendall Smith, Chief Physician Advisor Denial Research Group/AppealMasters

Summary: Scoring appeals for the opportunity for overturn should be part of everyone’s denial and appeal management process. Appeal scoring is a simple and effective tool that helps focus scarce resources on those denials that you are most likely to win. It can also give you insight into payer trends, payer behaviors, and appeal writer quality.

Join us as we show how to put the power of appeal scoring to work in successfully defending against aggressive denials. We’ll be sharing real case examples of utilizing a scoring tool to improve appeal outcomes, incorporating processes to automate escalation of winnable denials, and realizing the cost benefit of using a simple tool that you can design and implement yourself.

Click here to register!

Adding Human Intelligence to Denials Data

By Denise Wilson MS, RN, RRT

Senior Vice President Denial Research Group/AppealMasters

President AHDAM

Every appeal starts with a denial notice from the payer. The notice may come automatically through an electronic remittance advice (ERA), oftentimes referred to as an 835. The ERA represents the electronic transaction of the claim payment. The notice may come as the result of an audit of medical records, in which case the payer often issues a letter to the provider with an explanation of the reason for the denial as well as an 835. Either way, providers make use of the many data fields included in the 835, as well as the 837 transaction set (which represents claims data) to track and trend denials.

These two data sets are a good start when looking at denials data, but they don’t paint the entire picture. The electronic data sets represent primarily technical and administrative information about the claim and the payment. The dates of service, the location of the service, a listing of services performed, and the provider of the services are examples of data that can be gathered from the electronic transactions. And it’s data that can be turned into useful information. A provider can trend, by payer, the services or service locations being denied. A provider can trend the diagnoses being challenged in clinical validation denials. But that’s just the beginning of the story. Real insight comes from adding human intelligence to denials data. The additional human intelligence is required for success in proactively preventing denials.

Human intelligence comes in the form of assigning issues, root causes, and appealability scores to denials. The human data can only be determined by examination and review of the denial and related documentation such as the medical record, the coding summary, utilization and case management notes, patient accounting notes, authorization activity, payer correspondence, and the like.

Every denial should be assigned an issue. The issue represents the broad category of the reason the payer issued the denial. Issues can be as broad as medical necessity of a procedure or service (regardless of whether performed inpatient or outpatient because place of service is already identified through the transaction data), level of care, clinical validation, or coding. Adding specificity to the issue adds greater intelligence for denial management. For example, breaking out the coding issues by coding – DRG validation, coding – procedure, or coding – discharge status would help bring granularity to reporting.

A root cause assigned to a case indicates the internal process failure which caused the denial to occur. A root cause is defined differently than the issue, although they could be the same or similar in meaning. For example, a coding – discharge status (the payer denied the discharge status code on the claim) could have a root cause of coding error – discharge status, which would indicate the coder made an error in coding the discharge status. In this example the issue and the root cause are essentially the same. An example of a dissimilar issue and root cause might be an issue of level of care (the payer is denying payment for an inpatient admission) with a root cause of lack of a valid inpatient order. It was the lack of an order for inpatient admission (an internal process failure from the provider) that caused the payer to issue a level of care denial.

An appealability score represents the expectation of a favorable outcome of an appealed denial based on standards in medical necessity, coding, or clinical documentation integrity. Providers are encouraged to create internal appealability scoring tools. Appealability scoring helps identify the denials with the strongest and the weakest support for a successful appeal. The power of the tool comes from its use as the common denominator in comparisons that expose trends in appeal success and trends in payer behavior, and its ability to focus the appeals team on winnable denials. See the AHDAM webinar recording, “Successfully Identifying Winnable Denials” at https://ahdam.org/denial-and-appeal-management-webinars/ for more information.

Issues, root causes, and appealability scores are assigned after human review of the case by an experienced appeal specialist. Every provider should be using a tracking system for managing denials and appeals. It might be a spreadsheet, or it might be a sophisticated denial and appeal management software. Either way, transaction data (dates of service, CPT/HCPCS codes, claim adjustment reason codes, etc.) are likely being recorded whether through automated data feeds or through manual entry. But that’s only half the picture. The insight an experienced appeal specialist can add to that data is invaluable, especially in the work to proactively avoid denials. Tracking issues helps identify opportunities for investigation, discovery, and reversal of trends in cost centers and among providers associated with the highest rates of denial. Root causes identify opportunities for process improvement whether in documentation, coding, administrative, or billing practices. Appealability scoring uncovers trends in payer behaviors and opens the door for discussion with managed care departments. All of these actions create the groundwork for fewer denials.

About the author

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

THE BENEFIT

The Newsletter of the Association for Healthcare Denial and Appeal Management

January 2022

Our next webinar: Successfully Identifying Winnable Denials

Wednesday, February 9th, 2022, at 2 PM Eastern Time

Presenter: Denise Wilson MS, RN, RRT, Senior Vice President Denial Research Group/AppealMasters, President of AHDAM

Summary: Everyone in the denial and appeal management world knows that some denials have a greater chance of being overturned than others. The knowledge comes from experience, but many times it’s just a sense or a feeling of déjà vu. You’ve seen this denial so many times, you know the payer will uphold or you know they will overturn. Have you ever considered grading your denials by opportunity for overturn based on objective data? Using a grading system can help you focus scarce resources on those denials that you are most likely to win. It can also give you insight into payer trends, payer behaviors, and appeal writer quality. Join us as we teach you how to identify winnable denials.

Learning Outcomes: At the conclusion of the webinar, the learner will be able to begin to create a denial scoring system based on their provider’s unique make-up including payers, current payer trends, denial types, and denial reasons. The learner will be able to identify:

A benefit of utilizing a scoring system to identify denials with the best opportunity for overturn.
A data element crucial to identifying denials with the best opportunity for overturn.
A way to create a simple report that will use meaningful data to identify denials with the best opportunity for overturn.

Click here to register!

Battling Sepsis Denials Using Common Sense

By Kendall Smith, MD

Chief Medical Advisor at Denial Research Group/AppealMasters

AHDAM Advisory Board Member

I recently reviewed a first level appeal which had been upheld by one of United Healthcare’s auditors. The appeal (as most seem to involve these days) centered on the coding of sepsis during an inpatient stay. The patient had been hospitalized with pneumonia, hypoxia and hypotension with a SOFA score of two points. In United’s words:

This claim involves a 42-year-old male who presented to the facility for treatment of dyspnea. The provider cites disagreement with the removal of CODE(S) A41.9 (Sepsis, unspecified organism), suggesting that the patient met Sepsis-2 criteria and the patient also met QSOFA criteria.

United’s auditor then set forth an argument that I have seen with increasing regularity in these types of cases:

“While we acknowledge this patient had a low MAP that satisfies Sepsis 3 criteria, this alone would not validate the diagnosis of sepsis in the setting of pneumonia. The hypoxia in this patient is a manifestation of the infection in the lung(s), and therefore, not evidence of dysregulated immune mediated organ injury.”

The payer essentially argued that because the patient had pneumonia, they were discounting the hypoxia from the SOFA score. I’ve seen similar arguments trying to downgrade SOFA scores based on a patient’s pre-existing diseases such as COPD or CKD wherein the auditor argues that because the patient had some pre-existing chronic disease that dysfunction of that organ should be excluded from a SOFA calculation. How can you counter what seems like circular logic in these cases? The answer lies in pointing out that the (SOFA) criteria does not state that organ dysfunction within the same body system as the site of infection cannot be used as evidence of sepsis.

The denial letter incorrectly refuted the patient’s hypoxia as an indicator for sepsis, citing that the “hypoxia (P/F ratio) in this patient is a manifestation of the infection in the lungs and therefore, not evidence of dysregulated immune-mediated organ injury.” This statement is false and a complete misrepresentation of the Sepsis-3 criteria. The criteria do not state that organ dysfunction within the same body system as the site of infection cannot be used as evidence of sepsis. Hypoxia is not inherent to pneumonia as a disease process, meaning that not all patients with pneumonia develop hypoxia and not all patients with hypoxia simultaneously have pneumonia. Thus, the hypoxia certainly shows a level of organ dysfunction not found in all patients with pneumonia, representing more than just an infection within the lungs. As such, the only requirement of Sepsis-3 criteria in terms of SOFA score is that patients must have a score of 2 or more above baseline.

So, if you’re confronted with a sepsis denial where the auditor attempts to remove an acute on chronic diagnosis (acute on chronic kidney failure, acute on chronic respiratory failure) or argues that the infection itself (as in the pneumonia case above) was solely responsible for the organ dysfunction take a step back and bring forth some objectivity to your appeal. Show via AKIN or RIFLE criteria that the patient had acute kidney injury or using A-a gradients that the patient’s respiratory failure was objectively worsened because of sepsis. In cases where the auditor is arguing that the infection was causing localized organ dysfunction in a previously healthy patient (hypoxia in pneumonia, acute kidney injury in pyelonephritis) point out that for the auditor’s opinion to ring true that all patients with that disease would have hypoxia or acute kidney injury which is in fact untrue. When presented with the above argument, United reversed its position and overturned the denial at the second level of appeal.

About the author

His familiarity with managed care denials led him to design and implement a number of CDI programs, including those at the Cleveland Clinic in Florida and the MedStar Washington Hospital Center. He has served as a physician leader on hospital revenue cycle management teams while also serving as a the Physician Advisor for Clinical Resource Management. Dr. Smith is also an AHIMA ICD-CM/PCS approved trainer/ambassador.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

THE BENEFIT

The Newsletter of the Association for Healthcare Denial and Appeal Management

December 2021

Happy Holidays to All!

The Association for Healthcare Denial and Appeal Management Board of Directors wishes all our members and readers a happy and healthy holiday season. Working in healthcare is more difficult today than it ever has been. There’s no doubt the ongoing pandemic is straining our healthcare systems beyond what we’ve ever experienced. And, in the area of revenue cycle, the increase in payer audits and denials is challenging the financial viability of our hospitals and other healthcare providers. Our hope is that each of you finds some peace that will help restore your strength to continue to fight the good fight.

See you in 2022 for our next webinar!

The end of 2021 will see the association launching the first annual membership satisfaction survey and adding even more valuable education and resources to the website.

Our webinar offering will reconvene in 2022! We’re always open to suggestions for ongoing education, so let us know what you want to know!

You can contact us with your ideas at [email protected]

Uptick in UPIC Audit Activity

By David M. Glaser, Esq.

Shareholder Fredrikson & Byron

AHDAM Advisory Board Member

[NOTE: UPICs were created to perform program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching. Medicare Part C and D program integrity efforts are handled separately by one national contractor known as the Medicare Drug Integrity Contractor (MEDIC). The UPICs and the MEDIC work under the direction of the Center for Program Integrity (CPI) in CMS. https://med.noridianmedicare.com/web/jddme/cert-reviews/upic]

There seems to be a sudden burst of UPIC activity. Over the last couple of months I have heard from nearly a dozen hospital systems that have received post-payment medical records requests from Covent Bridge, which is a UPIC (Unified Program Integrity Contractor) whose jurisdiction includes Iowa, Illinois, Indiana, Kansas, Kentucky, Michigan, Minnesota, Missouri, Nebraska, Ohio and Wisconsin. One of my clients recently received the results of a different UPIC audit where Convent Bridge failed to apply the two-midnight rule, making up its own standard for inpatient status.

In that audit the UPIC denied the overwhelming majority of the one day stays it reviewed. For many of the denials the UPIC included the following purported justification:

The provider’s documentation did not support that an inpatient level of care was required to observe the beneficiary’s symptoms. The provider’s documentation did not include any other abnormalities that would require an inpatient level of care as opposed to monitoring an observation at the outpatient level. The documentation submitted does not support severity of illness or intensity of service for an inpatient admission. Therefore, the claim is denied.

The terms “severity of illness” or “intensity of service” are likely familiar to most of you. They’re commonly used in the industry. There is, however, one key place where those phrases do not appear at all: the two-midnight rule. The two-midnight rule focuses solely on the physician’s expectation of length of stay. The rule appears at 42 C.F.R. 412.3.

“Except [as specified below] an inpatient admission is generally appropriate for payments under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights. The expectation of the physician should be based on such complex factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs and the risk of an adverse event. The factors that led to a particular clinical expectation must be documented in the medical record in order to be granted consideration.”

There isn’t a reference to “severity of illness” nor to “intensity of service.” While there is a reference to the severity of signs and symptoms, it is in the context of how that effects the physician’s expectation of the length of stay. When it comes to determining whether the patient should be an inpatient there is only one question: “When the physician admitted the patient, did the physician reasonably expect that they would need two days of hospitalization?” If the physician expects they will be in the hospital for two days, the patient is an inpatient. Period. The UPIC applied the wrong standard in that audit.

While we don’t know if Covent Bridge will apply the right standard in the most recent audits, even the request has issues. It requests approximately 35 bullet points of material. Some of them are totally legitimate, seeking information necessary to determine whether care delivered was reasonable and necessary. They ask for the physician history and physical discharge summary and progress notes, laboratory and other diagnostic studies and any supporting documentation from an outside transferring facility. (A quick aside on this point. Ask your HIM Department whether they send outside records in response to medical record requests. Many HIM Departments are under the mistaken belief that they should only send records created by their organization, withholding records received from other caregivers. Somewhere in the HIM world, people got the terribly mistaken notion that a facility owns records, and that an organization should never release copies of other entities records it received as part of a patient’s care. There is so much wrong with that belief. First, it arguably is inconsistent with the information blocking rules, and it’s certainly going to make you fare worse in an audit. Your professionals saw and used those records. The auditors need to see them too. Too many HIM professionals are stuck on this misconception, and we must stamp it out.)

Returning to the UPIC requests, some of the demands are completely unreasonable. They want a copy of the Medicare card and state identification card for every patient. They claim that this permits them to investigate identity theft. But I don’t know of any requirement that the hospital ask for, let alone keep, a copy of the patient’s driver’s license. The red flag rules addressed that, but as clarified most hospitals are not subject to them.

The UPIC also requests copies of licenses or certification for all personnel in the beneficiary’s chart including physicians, nurse practitioners, and nursing. This makes little sense. In addition to it being a lot of work, copies of licenses do not prove anything except that the professional was, at some point in time, licensed. A license could have been suspended two weeks ago and the copy of the license will still appear valid. If the UPIC is so stuck on checking everyone’s licensure status, it can do what everyone else does, which is go to the local licensing board and determine whether the person is licensed. The good news is that Covent Bridges staff have been very pleasant to work with. In some cases they have shown some flexibility to withdraw requests for some records, including the licenses, though there has been variability analyst to analyst. But while pleasant, they’ve still insisted on receiving things like “a copy of your utilization review/case management policy and procedures as well as the name and version of the screening tool used.” Well, guess what, there’s definitely no requirement that you have a screening tool. You know what you, and the UPIC, should be using to determine Medicare patient status: the two-midnight rule. The two-midnight rule is the one and only screening tool for Medicare patients.

Up until now, I’ve never given a lot of thought to the authority that UPIC has to demand anything beyond the medical record. But now I have reason to analyze it because the UPICs have also been requesting to interview physicians. This is entirely unprecedented in my experience. The UPIC wrote my client a letter seeking a telephone interview with a physician. The request provided absolutely no explanation about a topic to be covered. The letter was addressed “Dear Provider.” “I would like to contact you to discuss claim activity recently submitted to Medicare where you were identified as the ordering/referring physician.” That’s it; no patient name, no claim number, no general topic. As Churchill would say, it is a riddle wrapped in a mystery inside an enigma.

The physician who received the letter orders a range of services, including durable medical equipment, prosthetics, orthotics, lab and imaging. Since the letter referred to “claim activity,” it could involve a single patient or multiple patients. If you are the lucky recipient of such a letter, what should you do? My advice is to have competent legal counsel reach out to the UPIC and ask for details about the inquiry. I am not a fan of allowing physicians, or anyone else for that matter, to submit to an interview without having a very solid understanding of the content of the interview. Even then, I recommend that if you agree to an interview at all, have counsel very familiar with UPICs and government investigations participate. UPICs are authorized to investigate fraud. They routinely make referrals to government investigators. One should treat an interview with a UPIC as comparable to an interview with a government agent.

One interesting question is whether you are required to agree to the interview. It is clear that the UPIC can request the interview, and the UPIC has the ability to stop payments if it finds fraud, but if there is an explicit obligation to agree to an interview, I am not aware of it. The bottom line is that you will want to be polite, and tread carefully, but I see no reason to throw a professional to the wolves alone. Get your counsel in the mix.

Many clients worry that involving legal counsel will make them look guilty. In fact, agents will sometimes say “If you’re innocent, why do you need a lawyer?” That is exactly backwards. Innocent people need lawyers even more than the guilty. When a guilty person gets in trouble, they arguably are getting what they deserve. By contrast, an innocent person in the crosshairs of the government is a true injustice. While involving legal counsel does not guarantee justice will be served, a good lawyer has the ability to increase the likelihood that the investigation stays on track. It is certainly true that investigators are frustrated when subjects get lawyers. And while I don’t normally advocate intentionally annoying someone, think about WHY the investigators are annoyed. Counsel makes the investigator’s job more difficult. When you’re the target, anything that makes the investigator’s job more difficult is good for you.

UPICs seem to be more active now than at any point in my career. If you receive any communication from one, you will want to make sure you fully understand all of your rights, and that the UPIC is neither overstepping its authority or misapplying the law.

About the author

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

November 2021

See you in 2022 for our next webinar!

The end of 2021 will see the association launching the first annual membership satisfaction survey and adding even more valuable education and resources to the website.

Our webinar offering will reconvene in 2022! We’re always open to suggestions for ongoing education, so let us know what you want to know!

You can contact us with your ideas at [email protected]

Trending Risk: Denial for Short Inpatient Stays + What to Do

By James Haering, DO, SFHM, CHCQM

AHDAM Advisory Board Member

The last several months have seen the resurgence of audits by CMS and commercial payers. One prime area of interest is the hospitalized patient with a short inpatient stay (short stay). This new level of attention places hospitals at increased risk of payment denials for inpatient services. Now is a good time to do a spot check of how your hospital is managing this category of admissions, hopefully before the auditors come knocking. Let’s take a look at some strategies to employ on the front end to monitor and manage short stays, and thereby decrease the risk of post discharge audit and denial.

Who is Auditing?

Since CMS implemented the 2 midnight (2MN) rule in October 2013, there have been audits of its use by hospitals in determining the medical necessity (MN) of inpatient stays. Since October 2015, the quality improvement organizations (QIO), KEPRO and LIVANTA, have been major players in these audits. However, this work was placed on hold in April 2019 after their contract expired. CMS awarded Livanta the sole national QIO claims review contract in early 2020, but this was contested by other players in the industry, leading to a pause in the work that has lasted into 2021. Finally, it was announced in April 2021 that audits by Livanta would resume later in the year, and in September, hospitals began to see additional document requests (ADR) from the QIO. Hospitals were told to expect a sample size consisting of 30 claims within a rolling 3-month period, with ADRs faxed (or mailed if no fax number is provided), to the point of contact listed in the facility’s Memorandum of Agreement on file with Livanta.

A Brief Review of the “Two Midnight Rule.”

Implemented in October 2013, CMS established a presumption that hospital stays spanning two or more midnights after the patient is formally admitted as inpatient are considered reasonable and necessary for Part A payment absent any evidence of systematic gaming, abuse, or delays in provision of care in an attempt to qualify for the 2MN presumption. Unlike the private payers, the Medicare stays exceeding a benchmark of 2MN are not the focus of most medical reviews for correct status.

The 2MN rule has been revised by CMS multiple times since it was implemented. The most impactful modifications have been the introduction of exceptions to the requirement of a LOS exceeding 2MN. The categories, and proper use of exceptions should be ingrained in the minds of all admitting physicians, and UM staff. Regardless of the exception used, it is critical that documentation reflects the physician’s expectation for an IPS, and any unforeseen outcomes that qualify for an exception.

Procedure is on the Medicare Inpatient Only list
New Mechanical Ventilation Initiated During Visit
Unexpected Recovery
Patient leaving AMA (against medical advice)
Death
Transfer to another acute care facility
Election of Hospice Care
“Rare and Unusual” exception

There is one more situation recognized by CMS, described as the “rare and unusual,” exception. Under this modification, inpatient stays of <2MN may be deemed medically necessary, if the patient’s clinical condition, and medical management could only be provided in the inpatient setting. I recommend against the routine use of this exception. Outside an CMS-deemed inpatient only procedure (IPO), there are vanishingly few situations where someone is so critically ill that only the inpatient setting is appropriate, yet the predicted LOS is <2MN. In cases with this severity of illness the hospitalization will exceed 2MN, and an earlier discharge suggests the patient has an earlier than expected recovery. CMS expects that stays under 24 hours rarely qualify for an exception to the benchmark of a 2MN stay for an inpatient stay.

What is a Short Stay?

When announcing the impending resumption of audits, CMS modified its long-used terminology stating

“Formerly known as the “Two-Midnight Rule Review,” claim reviews for short hospital stays focus on the claims submitted by providers when a patient was admitted to the hospital as an inpatient but discharged less than two days later. Inpatient admissions are generally payable under Part A if the admitting practitioner expects the patient to require a hospital stay that crosses two midnights and the medical record supports that reasonable expectation.”

Under Traditional Medicare Insurance, any hospital episode of care with a LOS less than 2MN following the placement of an inpatient order, is considered a short stay. These episodes are at risk of audit under the reinvigorated QIO audits. With commercial payers, the LOS threshold of a short stay can vary by the diagnosis, payor standards, or hospital specific contract language. Hospitals when screening for short stay, under commercial payers, may decide to be more conservative in their cutoff, such as setting the bar at stays less than 72 hours. Regardless of the definition, there are several situations that lead to the appearance of a short stay, and thereby trigger an audit. More on this later.

The core characteristic of a short stay is a LOS so short that payers may flag the case for audit to determine if care may have been provided at a lower level, e.g., observation services (OBS). Any LOS which is below the average for patients with the same or similar diagnosis, is a target. In addition, certain diagnoses may be targeted when there is a large discrepancy between the actual and expected LOS. Consider a patient with septic shock, who is discharged (alive) less than three days after admission. In general, the diagnosis of sepsis is a common target of the payors due to a (actual or perceived) high error rate. A short stay with recovery and discharge of a critically ill patient with septic shock would be uncommon, and may suggest over coding.

Occurrence Span Code 72 (OC72).

This code is commonly used, but not required, to indicate that the patient has passed two necessary midnights in the hospital, but less than two as an inpatient. Occurrence Span Code 72 on the face of the claim informs providers and auditors of the total (including observation and inpatient) number of nights of hospital care. There are debates as to whether it is better for hospitals to include or exclude OC72 from the claim. A deeper discussion is outside the scope of this article, but for most hospitals, I recommend its use.

Hospital encounters with an inpatient LOS <2MN should be screened as a short stay, even if there is a preceding period of observation services and total LOS exceeding 2MN, or 48 hours. Make sure to note the specific date and time of care initiation (especially transfers), the total LOS from initiation of care, and the presence of an OC72 if applicable.

Review your Short Stay Game Plan.

Once you’ve established the short stay parameters for your facility, you can now perform a gap analysis and identify your vulnerabilities. Areas to assess include

Admission orders. What wording is used in the physician statement regarding the LOS?
Medical necessity statements. How are physicians documenting the MN for inpatient admissions?
Monitoring short stay admissions. What is the internal process for identifying and reviewing short stay encounters? Is your screening process capturing too many false short stays?
Denials and appeals. What is your strategy for appealing denials of short stay encounters?

Admission Orders and the Physician Statement. If an auditor were to read the medical record, is the physician’s intent for inpatient status immediately evident or easily found? Or, is this information buried in the chart and likely to be overlooked by the auditor? Trusting that the payor will be thorough, is not a good strategy, when experience suggests they are more likely to skim through the record. Is the order for admission clear or ambiguous, and do they support or hurt the defense of a short stay?

Medical Necessity Statements. How well does the physician convey the MN of the admission? Examples of physician documentation identified during chart audit include;

The defense of a short stay is weakened when the physician’s reasoning for inpatient status is missing.
Weak support. “The patient requires inpatient treatment.”
Moderate support. “His worsening urinary tract infection despite oral antibiotics, requires inpatient management with a LOS exceeding three midnights.”
Strong support. “He is at high risk of progression to severe sepsis, due to his renal transplant on immunosuppressive medications, and having failed > 72 hours of appropriate outpatient antibiotics.”

While stronger arguments tend to be longer, it is the statement’s ability to convey a picture of the medical necessity, rather than the length, which is key.

Monitoring Short Stay Admissions. The utilization management protocol at many hospitals includes flagging any Medicare cases that have a LOS <2MN. Fewer, will also identify commercial payor inpatient status with LOS <48 hours. I recommend a process encompassing all payers.

Cases should be identified as early as possible, and preferably before the submission of charges to the payer. Earlier review, and correction of chart deficiencies, is likely to result in better outcomes such as decreased denials. Through manual processes, or utilizing artificial intelligence (AI), these cases may even be flagged before, or immediately after discharge. Manual processes tend to be inconsistent and labor intensive. For these reasons, we are likely to see increasing use of AI processes.
Cases may be screened by senior UM RNs, or automatically forwarded for secondary review by the physician advisor (PA). Involvement of a PA experienced in denial and appeals will allow crafting of a preemptive statement in defense of the short stay.
Consider screening specific diagnoses at high risk for audit and denial following a short stay. This will vary by hospital, but common targets are sepsis, acute respiratory failure, and complex pneumonia.
Make it a practice to screen all traditional Medicare with a time from the inpatient status order until discharge of <2MN.
Discuss your hospital’s target cutoff for commercial payers.
Review your escalation policy. Which cases are sent for secondary review by the PA?
Decide whether you’ll include or exclude the time spent under observation when determining whether an episode of care should be treated as a short stay.

The Appearance of a Short Stay, AKA False Short Stay. What do we mean by “appearance” of a short stay? There are several circumstances where a cursory review may suggest an encounter is a short stay, but with a more thorough search, it becomes evident that the total LOS exceeded 2MN or 48 hours. The most common mistake leading to a false short stay, is not paying attention to the clock, and the time the patient began receiving care.

A hospital LOS can be calculated based upon the time between the admission order and discharge order. Or, it can be measured as the time between start of care and end of care. Hospital data sets most often report the former, when short stay admissions should be judged by the latter. Be aware of how your facility captures the LOS. To illustrate this further (for the following, assume the payor is traditional Medicare).

Scenario 1. Care begins in the ED at 2000 on day one, an IPS order is placed at 0200 on day two, and the discharge is 1100 on day three. The LOS from the admission order to discharge was <2MN. However, calculating LOS from the start of care, until the end of care, the total time was >2MN, and meets the 2MN benchmark.

Scenario 2. After presenting at 1400, a patient is hospitalized with observation services for evaluation of chest pain. Testing shows an acute pulmonary embolism. The second day, there is instability for discharge with mild hypoxia and continued pain. An IPS order is placed. He discharges on the morning of day three. This scenario qualifies for the use of OC72. If the hospital reports OC72, the payors’ filters should alert them to a false short stay. The benefits v. risks of reporting OC72, is a separate discussion, but for most hospitals, I recommend its use.

Scenario 3. Transfers. At 2000, a patient begins care at hospital A., is transferred to Hospital B, arriving at 0200 on day two, and an IPS order is placed. He is discharged on day three at 1100.. His LOS at hospital B is <2MN, but the total LOS since initiation of care is >2MN. This appears to be a short stay, but actually meets the benchmark of >2MN.

Scenario 4. Outpatient procedures. Again, the clock starts with the initiation of care. An outpatient elective total hip arthroplasty is performed. On day two, she is not meeting discharge criteria, with poor performance during physical therapy, and uncontrolled nausea. An order for an inpatient is placed, and on day three she is discharged home. The LOS since placement of the IPS order is < 2MN, but the total LOS is >2MN.

PEARL: Many EMRs will display the LOS based on the most recent order. If your physicians like to place several orders, then the care team may lose track of the total LOS. I’ve sat through many multidisciplinary rounds, where the team reports the LOS is 1 day, yet the true LOS is 3+ days. To counter this, I set my EMR screen to display the arrival date, not the admission day. Many EMRs allow this option.

PEARL: CMS expects that stays under 24 hours rarely qualify for an exception to the IPS benchmark of a 2MN stay. To avoid triggering denials, care should be taken to ensure that IPS orders are placed as early as possible, the EMR captures the correct time of admission, and that physician practices such as placing multiple admission orders, are not contributing to the appearance of IPS falling below 24 hours in length.

Denials and Appeals – How to Defend the Short Stay. As a physician advisor there are several approaches and arguments I employ in defense of the short stay. Medical and surgical admissions may differ in some respects. Assume for the purposes of discussion, that we’re talking primarily about medical admissions, unless otherwise stated. The exact approach will vary depending upon the scenario, and payer.

Expected, or predicted LOS. Hopefully, your physician has documented an expected LOS >2MN, or 48h. But what does “expected” mean? The expected LOS can be based on
- Diagnostic Related Group (DRG). If the patient’s DRG, has a typical LOS of 3.5 days, it is reasonable for the attending (and reviewer) to predict the inpatient status thresholds as defined above will be met. PEARL: If the ALOS is >2MN, and the patient has other significant comorbidities, I may argue “Based on the clinical presentation and comorbidities, it is unreasonable to expect the patient will/would have a faster than expected recovery,” or similar words.
- Previous episodes of care. A prediction of the current LOS can be based on the patient’s previous admissions. Consider a person hospitalized for the fourth time this year, with COPD exacerbation. All the previous stays resulted in a LOS of 5+ days. It is reasonable for the attending to predict this hospitalization will be similar to the others and therefore place an inpatient order. PEARL: My argument in this case will include “Similar admissions for this patient have far exceeded the maximum appropriate duration of observation services,” or similar wording.
- Comorbidities. LOS predictions may be based on the presence of other issues that confound the hospital course and contribute to prolonging the medically necessary LOS. Some examples include patients requiring contrast studies, who also have acute kidney injury, or patients requiring anticoagulation for acute pulmonary embolism, but also with worsening anemia in the setting of subacute Gastrointestinal bleeding. One of the reasons we do not adhere solely to clinical guidelines such as InterQual or MCG, is that an experienced clinician can assess the entirety of the medial record and make predictions regarding the most likely duration of the hospitalization, or at least, be reasonably certain the LOS will meet IPS thresholds.
The patient’s condition at the time the inpatient status order is placed. Payors often forget the MN of an inpatient hospitalization is judged on the information available to the attending physician at the time the decision was made for inpatient status. Any subsequent information, including the overall clinical course, is not to be included, unless that information further supports the original impression that inpatient status was medically necessary. In other words, the fact that everything turned out o.k. Is not a basis for denying an inpatient status. If you disagree, then consider whether hospitals should be paid only for the abnormal MRIs during workups for possible stroke, or only the abnormal stress tests when ruling out coronary artery disease. When defending an inpatient denial, the standard remains; at the time the attending placed the inpatient status order, there was medical necessity for the status, and an expectation of >2MN.
The clinical course. Many of the short stay admissions begin with observation services, with later conversion to inpatient status. By their very nature, this group tends to have a lower overall acuity, and intensity of service, making them a prime target for denials. With most appeals, we should include clear statements that the patient “failed observation services,” or “failed to meet discharge criteria, despite appropriate observation services.”
The duration of care. For inpatient status with the appearance of a short stay, I will include specific wording, describing at a 6th grade level of reading, why the total length of care was really in excess of 2MN or 48 hours. For example, “this patient presented to an outside hospital on 11/2/2021, with initiation of care at 2300, transferred to Good Community Hospital on 11/3/2021. The inpatient order was placed at 0730. With the discharge date of 11/4/2021, his total length of stay exceeded 2MN.”
CMS exceptions. The medical record reflects a CMS-recognized exception to the 2MN benchmark. It is critical that there is clear and easily discoverable documentation of the CMS exception for any inpatient stay lasting <2MN between the start and end of care. Early screening at or near the time of discharge, and correction of any documentation deficiencies, will save the work doing downstream appeals.

PEARL: A common mistake is to assume a formal order of leaving Against Medical Advice is required for this short stay exception. In reality, it is a much lower threshold. The chart simply needs to show that it was the patient’s preference to leave, and the physician recommended continuing the hospitalization.

PEARL: There are times when the attending physician ordered inpatient status, the medical necessity review shows it is more appropriate for observation, and the case is escalated to the physician advisor on day 3. If the same case were sent on the first day of hospitalization, the determination would be observation. In these situations, I argue ” the hospital course and actual length of stay for medically necessary care, exceeds the 2MN benchmark, and supports the initial decision by the attending physician for inpatient status.”

Continue to Improve.

Learn from your internal audits, and from the short stay encounters denied by payers. In the end, any chart audit should reveal four patient categories.

False short stays. Inpatient stays with a total LOS >2MN, including time since care started as an outpatient, or while under observation services.
True inpatients with a CMS recognized exception
True observations, incorrectly hospitalized as inpatient.
True outpatients, incorrectly hospitalized as inpatient

The ratio of these groups at your facility will provide great insights into how the hospital is performing. Armed with this knowledge, system improvements can be developed. Since each category has unique solutions which are often hospital and market specific, I recommend engaging your Physician Advisors to help craft your next steps

Summary.

With the QIO audits up and running as of September, it is more important than ever to take stock of how your hospital is tracking and addressing the short stay admission. The work done on the front end by the UM team and the attending physicians, will set you up for success with downstream denials. Review the admission orders for clarity. Make sure the process screens for and correct any deficiencies in documentation of CMS-recognized exceptions to the 2MN benchmark, such as the patient who recovers faster than expected. Define your criteria for which cases will be flagged as a short stay and when to escalate cases for physician advisor review. Be able to identify cases giving the false appearance of a short stay, and consider ways to mitigate the risk of their being denied. And, if you are unsure where to turn next, consider reaching out to your peers through AHDAM.

About the author

James Haering, DO, SFHM,CHCQM, serves as a Senior Physician Advisor, and consultant with JBH Solutions.

A practicing hospitalist with 30+ years of clinical practice, at all levels of patient care, including outpatient clinics, Acute Care Hospitals, Skilled Nursing Facilities, and Psychiatric hospitals.

With 20 years of Utilization Management experience, Dr. Haering has collaborated with health systems, commercial payors, Independent Review Organizations, and Medicare. He is the founding physician and former Vice-President of Sound Physician Advisory Services. He has presented on a wide range of topics including Denials and Appeal Management, system re-engineering, process improvement, compliance, physician alignment, clinical documentation improvement, and care coordination. His experience across hundreds of hospitals, combined with active clinical practice, provides an acute understanding of today’s challenging healthcare environment.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

October 2021

Next Complimentary Webinar!

Find Appeal Success by Creating Your Own Evidenced-Based Guidelines Library

Wednesday, November 3rd | 2PM – 3PM Eastern Time

Winning medical necessity denials comes down to arguing that care provided met the standard of care in the medical community. If a surgeon amputates a finger for paper cuts, you should not expect to be reimbursed. But when care provided is representative of the standard of care for the condition present, the provider, and the patient, should expect the care to be covered. Sounds simple, right? During the recent AHDAM webinar on The Power Behind Standards of Care in Successfully Appealing Medical Necessity Denials, we promised to teach you how to create your own evidence-based guidelines library to include snippets of guidelines that can be incorporated into successful appeal arguments. We hear you, no one has time to research standards of care for every appeal. Let us show you how to develop a mechanism that will have a direct, positive impact on the efficiency and effectiveness of your appeal writing.

Presenter: Denise Wilson, MS, RN, RRT, Senior Vice President, Intersect Healthcare + AppealMasters

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Keep Pushing Back

By Denise Wilson

Senior Vice President AppealMasters + President AHDAM

People who know me know I’m a rule follower, for the most part. I heard the other day that female drivers are more apt to use a turn signal at an empty intersection with no cars around than their male counterparts. Not to introduce a female/male discussion here, but, yes, I admit, I feel just a little out of place turning at an intersection without using a turn signal even if no one else is around. Admittedly, though, I do sometimes ignore the urge to use the turn signal in that scenario and tell myself, it’s OK.

I learned denial and appeal management from appealing Traditional Medicare denials. There’s not much about the Medicare appeals process that I don’t know inside and out. The process is very structured and there’s no wiggle room if the process isn’t followed precisely. This is especially true when it come to timeframes for filing appeals. Medicare defines the filing date as “the date received by the appropriate contractor in the corporate mailroom, the date received via facsimile, or the date received in the secure Internet portal/application, as evidenced by the receiving office’s date stamp on the request.[1]” If your appeal is filed one day late, you’re pretty much done unless you have a really good reason for late filing.

This is the story of an appeal for a hospital in New York that has somehow gotten stuck at the Level 2 reconsideration step of the appeals process for late filing when, in fact, the appeal was filed timely. I have been working appeals for seventeen years and I have never seen this happen until now. For many of those years CMS had one Qualified Independent Contractor (QIC) that handled all of the Level 2 reconsideration appeals for Part A claims. I can’t recall ever having an issue with timely filing that couldn’t be resolved through formal, written dialogue during the time when all Part A Level 2 reconsideration appeals were filed at one agency.

In this case, a 7-day hospital inpatient stay that occurred in 2017 was selected by the Recovery Audit Contractor (RAC) for DRG validation review. The audit occurred in 2020 and the unfavorable Review Results Letter, stating an ICD-10 code should be removed from the claim, was issued 8/4/2020. A Level 1 redetermination appeal was timely filed to the Medicare Administrative Contractor (MAC) but was dismissed by the contractor for late filing. In the decision letter the contractor states the appeal was received in their office on 2/1/2021 and the initial determination for the services in dispute was issued on April 19, 2017. Two statements, both of which are correct, but also don’t belong together. The initial determination (which was payment in full) issued in 2017 has no bearing on the RAC’s revised determination issued in 2020.

So, let’s do the math. Although the Review Results Letter was dated/issued 8/4/2020, the actual adjustment to the claim (the takeback) was not processed by the MAC until 10/5/2020. Remember, after a RAC audit, 30 days are allowed to pass in order for the provider to participate in a discussion with the RAC if they so choose. After the 30-day discussion period, the RAC then notifies the MAC to adjust the claim. The claim adjustment is the trigger to start the 120-day timeframe for a Level 1 appeal. 120 days from 8/4/2020 is 2/2/2021, one day after the appeal was received in the MAC office. So, the appeal was timely filed, yet, incredulously dismissed for late filing because, according to the MAC, four years had passed since the initial determination/payment on the claim.

So, what comes next? When the MAC dismisses a claim for late filing, the provider has a choice of following one of two pathways. First, if the provider believes the dismissal is incorrect (that is, the MAC was wrong in dismissing the appeal), the provider can request that the QIC review the dismissal. The provider has sixty days to make the request to the QIC. The QIC’s decision on the matter is binding and not subject to further appeal. The second pathway is used when the provider has good and sufficient reason for the action that caused the appeal to be dismissed. For example, if the provider knowingly filed the appeal late, but had a really good reason for late filing, the provider can appeal back to the MAC and ask them to vacate the dismissal. The provider is allowed six months to file back to the MAC.

So, this should be an easy fix. The MAC made a mistake in determining timely filing. A request to the QIC to review the dismissal should set the MAC straight. Well, that isn’t exactly what happened. The request was made to the QIC, but the QIC agreed with the MAC that the appeal was filed late. The QIC explained that the provider did not show good cause for late filing. Wait. What? The provider does not need to show good cause for late filing because the appeal wasn’t filed late. Now, remember, the QIC’s decision in this matter is binding. There is no further option for appeal.

It’s hard to fathom that two agencies in a row could mistake a timely filed appeal as untimely. This is when you have to go beyond the rules, outside the established process in order to find justice. An email was sent to the director of the QIC explaining the circumstances and asking for another look at the appeal. The QIC obliged by reviewing the case and issuing a confirmation of their original agreement with the MAC that the appeal was untimely filed. The confirmation letter was signed by the same appeals specialist who issued the original agreement with the MAC.

With no assistance from the QIC, the provider has turned back to the MAC for help. Multiple follow up calls with the MAC have resulted in multiple representatives confirming that upon review of the case, the appeal was in fact filed timely and there is no reason why it should have been dismissed. Numerous attempts have been made by the MAC representatives to escalate the case for re-review and fair resolution, but so far, their efforts have only resulted in decisions that the appeal was dismissed for late filing. If the most recent request for resolution of the dismissal is unsuccessful, the next step will be to file a complaint with the CMS regional office[2].

It’s certain that this experience has emphasized the need to keep pushing on when you have followed all the rules, received an underserved outcome, and been told that’s the end of the road. This is when you have to go outside the rules and the established process to find justice. I am optimistic this dismissal will eventually be vacated, but only because of the efforts to go outside the established process.

[1] Medicare Claims Processing Manual, Chapter 29 – Appeals of Claims Decisions, 310.2 – Time Limit for Filing a Request for Redetermination, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29pdf.pdf

[2] https://www.cms.gov/Medicare/Coding/ICD10/CMS-Regional-Offices

About the Author:

Denise Wilson serves as the Senior Vice President at Denial Research Group – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise is a Registered Respiratory Therapist, Registered Nurse, and holds a master’s degree in Management Information Systems from the University of Illinois, Springfield.

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

September 2021

Next Complimentary Webinar!

Find Appeal Success by Creating Your Own Evidenced-Based Guidelines Library

Wednesday, November 3rd | 2PM – 3PM Eastern Time

Presenter: Denise Wilson, MS, RN, RRT, Senior Vice President, Intersect Healthcare + AppealMasters

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Near-Death of a Medicare Appeal

By Taryn Schraad

President and Founder BAC10 Solutions, LLC, AHDAM Advisory Board Member

With Covid-19 infections multiplying at warp speed in 2020, Medicare waived many services requirements to expand healthcare access for beneficiaries under safer conditions. Medicare also promised flexibility in the delivery methods and locations of those services, along with some leniency regarding oversight and auditing of waived services. Although this news was welcome to the healthcare community, these waivers set the stage for confusion, misinterpretation, and another avenue for fraudulent coding and billing.

One of those waived services was the expansion of telehealth visits and a roll-back of the strict regulations that applied to the locations where telehealth services can occur. For example, during the pandemic, Medicare allowed beneficiaries to obtain their Annual Wellness Visit, code G0439 and a 100% covered benefit via video or telephone in their own homes. Waiving these telehealth location and site regulations helped Medicare beneficiaries during a tumultuous time of infectious disease spread.

Unfortunately, this was precisely how my mom became a victim of inappropriate billing. Early in the pandemic, she received a telehealth visit from a podiatrist, a specialist who treats foot, ankle, and lower extremity disorders. During what my mother thought was a phone call to assess her feet, calluses, and toenail conditions, the podiatrist inappropriately charged my mother and Medicare for an Annual Wellness Visit. Yes, you read that correctly. A podiatrist billed Medicare for an Annual Wellness Visit, and Medicare paid that bill. What’s next, optometrists charging for annual mammograms?

Due to the podiatrist’s inappropriate and inaccurate use of the code G0439, Annual Wellness Visit, my mom’s ability to get coverage for her actual wellness visit from her primary care physician later that summer was rejected by Medicare and denied. She was then balanced billed for this service. Thus, she began her long 18-month journey in the Medicare appeals process to straighten out a billing mess.

Even though I have worked in healthcare for most of my career, much of it directly involved helping hospital providers resolve insurance payment denials; this was my first experience handling a billing dispute for a Medicare beneficiary. Up to this point, I had only assisted my mom with this issue from the sidelines. As a retired nurse, she assured me that she would get this issue resolved.

Calls asking the podiatrist clinic to correct and recode her telehealth visit were unsuccessful. They refused and then dared to contact my mother’s primary care office, asking them to change their code – which, of course, was flatly refused. After several calls with the podiatrist clinic, they informed her that if she was unhappy about their billing practices, she didn’t have to attend their outreach clinic for her podiatry services. This bullying tactic made my mom quit attending the outreach clinic and getting the much-needed treatment required for diabetic foot care.

My mother then appealed to Medicare but was denied because they had already paid for her annual wellness visit – to a podiatrist. Then she was sent on a wild goose chase to the insurance commissioner, who could not assist her in this plight. Mom kept copious notes of days, times, and conversations. A heroic effort on her part, yet no one seemed to be genuinely listening to her issue.

After a year and a half, stacks of bills, copies of forms, many Medicare Summary Notices, and countless logged hours of phone calls, mom was exhausted. She submitted a second-level appeal called a Reconsideration to Medicare and managed to get her primary care physician paid for her proper Annual Wellness Visit. Yet, she was still sore that the podiatrist had “flown under the radar” for erroneous billing, a problem other Medicare beneficiaries had likely suffered. Plus, they had retained their Medicare payment and were left unscathed through this whole ordeal. She had also lost faith in the Medicare appeal process, referring to it as a paper pit ripe for a match.

I finally convinced my mother to let me do an in-depth review of her documents and see if I could make sense of what had happened, identify any outstanding bills, and assist with resolving unsettled issues. Here are some helpful tips if you dispute a medical bill or are assisting someone else with this task.

Make sure you are authorized to speak on behalf of the person you are helping. If not, the victim will need to relay everything said and done between you and the provider, or several three-way calls will need to take place to get the issue resolved.
Keep detailed notes of dates, times, and who you spoke with about the issue.
Obtain a detailed bill of the service under dispute. A detailed bill provides a description and price of each charge.
Cross-reference the service date, codes, and charges under dispute with your insurance benefit statements and payments, so you understand precisely what copays or deductibles are your responsibility.
When documenting your dispute and submitting an appeal, stick to the issue at hand. Don’t be too broad or vague about the predicament. Be concise and to the point, and don’t muddy up your message with unnecessary details.

Although there are no guarantees of a successful resolution when you are dealing with healthcare disagreements, my mom had done the right thing by disputing this billing issue. It had resulted in her primary care physician receiving their payment from Medicare for her Annual Wellness Visit. Sadly, I am not sure she articulated clearly in her appeals to Medicare the podiatrist’s inappropriate coding and billing practices. I will now assist my mother in filing a grievance with Medicare to report the podiatrist’s coding and billing behavior including their unethical and bullying comment suggesting my mother forgo her foot treatments if she is not happy. Perhaps we can provide a clear message to Medicare so they will launch an investigation into the billing and coding practices of the podiatrist and recoup their payment.

About the Author:

Taryn Schraad is the President and Founder of BAC10 Solutions, LLC. A compliance and denials and appeals consulting company linking complicated regulations to practical workflows.

Taryn Schraad, President and founder of BAC10 Solutions, specializes in Regulatory Compliance Consulting services. Taryn has over a decade of experience helping large and small organizations capture accurate and comprehensive documentation in clinical and revenue cycle workflows. Taryn uses that experience to customize a Compliance Work Plan for providers, scaled to meet the metrics that support an effective Compliance Program. As an RHIA, CHC, and CPMA, Taryn links complicated regulations to practical workflows in compliance with regulatory standards. Taryn has supported healthcare providers as an HIM Director, Audit, Denials and Appeal Coordinator, Internal Auditor, Chargemaster Senior Analyst, New Service Coordinator, and Compliance Consultant.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

August 2021

Next Complimentary Webinar!

The Power Behind Standards of Care in Successfully Appealing Medical Necessity Denials

Wednesday, September 15th | 2PM – 3PM Eastern Time

Payment for medically necessary services always comes down to whether treatment proposed or provided is equivalent to the current standard of care. Standards of care are used to determine patient status in the hospital as well as coverage of procedures or services. Join us as we present the power behind leveraging standards of care in medical necessity arguments for inpatient and outpatient medical services.

Presenters: Denise Wilson, MS, RN, RRT, Senior Vice President, Intersect Healthcare + AppealMasters & Kendall Smith, MD; Chief Physician Advisor, Intersect Healthcare + AppealMasters

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Insurance Companies’ Complex Case Managers – An Often-Overlooked Resource

By Reggie Allen, MBA, RN

Chief Operating Officer

CHRISTUS Spohn Shoreline/Memorial Hospital

Trauma patient Joe was still in an acute care bed on a ventilator and dialyzed daily despite being medically stable and ready to move to an acute, long-term care facility. After multiple attempts to find an alternative placement for him, there appeared to be no facility contracted with his insurer that would take him as a transfer because of his ventilator dependency and need for dialysis. As the length of stay closed in on a year, a senior member of the team called the insurer and, after some run-around, he was finally transferred to a complex case manager – who resolved the issue in 20 minutes. The insurer’s complex case manager transferred the patient to a facility outside the area. It is important to note that the accepting facility was not listed in the insurer’s published network of providers, nor were they told of this site before the exec’s call. The failure of the case management department was not due to the lack of trying, but in not knowing about this resource from the beginning of the patient’s admission.

It is important to understand that the insurer is not motivated to move a patient to another care venue even when payment is denied for lack of medical necessity. This works to their advantage as they can count the acute care stays in their utilization statistics gained from the billing but do not have to use their money to pay for the care. Sometimes pressure may be exerted with calls and lodging complaints with the State Department of Insurance or other oversight agencies. But before you get to that level of frustration, remember that all insurers have dedicated case managers that oversee the day-to-day case, and most have specialists for complex cases. They usually have the authority to negotiate with non-contracted venues and specialty providers if their network cannot serve a particular patient’s needs.

The complex case managers serve as a telephonic-based resource for patients, families, and caregivers. They are responsible for the care planning of complex patients, including establishing treatment goals and providing expertise in the subject matter for education, consultation, and training when needed. This position also serves as a liaison between the insurer, the patient/responsible party, physician(s), and facility case managers (Health Care Support n.d.).

This service can be accessed by a member, physician, or care facility. Most encourage direct participation with the member/patient to provide better advocacy in the movement through a complex field of care, whether inpatient or outpatient. These case managers may be nurses or social workers working with adults or children (Aetna Better Health of Pennsylvania n.d.). The scope of their work spans multiple issues from drug addiction, mental health, transportation to and from care, childhood developmental delay, and medical and surgical treatments. They also arrange for home health, DME, and any specialty needs of the patient.

Major health maintenance organizations (HMOs) that are accredited by the National Committee on Quality Assurance (NCQA), such as Anthem Blue Cross, have case management and disease management programs with objectives and outcomes described (Anthem Blue Cross 2015). One program, blue California, requires a credentialed (network approved) primary care or specialist to make the referral to that complex case management program. Enrollment criteria for the complex case management program include (blue California n.d.):

Major organ transplant,
Major trauma,
Four or more chronic conditions,
Three or more admissions within 12 months,
Same or related diagnosis 30-day readmission,
Poly-pharmacy utilization consisting of more than thirty prescriptions per quarter, and
Cancer diagnosis requiring multiple modalities with complex care coordination across multiple disciplines.

Other conditions include (Central California Alliance for Health 2021):

Poorly controlled chronic illness or new or worsening complications,
Obesity or bariatric patients,
HIV/AIDS,
End of life,
Complicated wounds,
Stroke with complications,
Worsening debilitating diseases such as multiple sclerosis or Parkinson’s, or
Seizure disorder with complications.

Some insurers have transitional care for special needs members. This typically kicks in upon transfer to another venue of care or home for a member with special needs. It can provide another resource for your facility case managers to access.

The Center for Medicare and Medicaid Services (CMS) has a Special Needs Plan (SNP) intended to support patients with complex medical issues (NCQA 2009). This document outlines the requirements for an NCQA review as contracted by CMS and includes referral sources and activities required of this program. Knowing this requirement may assist the hospital case managers in locating other resources for the complex managed Medicare or Medicaid patients.

CIGNA, another major health insurance company, promotes its internal case managers to patients and providers (Cigna n.d.) by offering the following services:

Coordinate access to care,
Explore service and funding source alternatives,
Monitor progress in establishing goals,
Assist with coordinating discharge planning and follow-up, and
Help ensure the patient’s benefits are used effectively.

Health insurance companies have these programs to mitigate their risk of high-cost claims by proactively managing the utilization of medical resources, in other words, controlling cost. They also benefit from knowing about potential catastrophic costs as early as possible to notify their reinsurance carrier. This reinsurance is insurance for the insurance company and is intended to reduce the risk of a high-cost claim (healthinsurance.org n.d.). Since submissions for this claim with the reinsurance company may be complex and time-consuming, preparing these claims is an essential part of the complex case manager’s responsibility. While this process is invisible to the provider or patient, it is vital to the primary insurance company that seeks to limit its risk. Payment of a claim submitted and adjudicated is run through the primary insurer regardless of the reinsurance payment.

The impact of an unnecessary long length of stay in an acute care setting is a quality issue as both overutilization and underutilization are quality of care indicators. Complex cases are significant contributors to the cost of care through hospital resource use. In addition, the patient’s share of these costs can, and often do, lead to personal bankruptcy and significant stress on the patient and their family. Consequently, the hospital case manager must know and use all the resources available, including those of the insurance company.

Had Joe’s case manager known of the insurer’s complex case manager, they could have instituted that program at Joe’s admission or as soon as they recognized the complexity and prognosis of his case. While the insurer is not financially incentivized to move a patient to a lower level of care, they deny payment beyond the initial treatment due to lack of medical necessity – they are obligated to work proactively with notice of the case. This is yet another reason to know the payor source for all cases.

The key to complex case management is early identification – the earlier, the better. When a difficult case is first identified, the case manager must:

Determine who can arrange complex case management with the insurance company.
Contact the insurer and make sure a complex case manager is assigned.
The hospital case manager needs to get all the contact information, including the case number, the name, direct telephone number, fax number, and address of the case manager.
Plan daily calls to the insurance company’s complex case manager with thorough documentation of all communication.
The complex case manager should be notified with transfer assistance requested as soon as the patient can be safely transferred. If the transfer is not made on a timely basis for reasons of lack of adequate network providers and venues of care, the insurer should be informed that no denial of payment or reduced rate will be accepted.
If this fails to accommodate the transfer, elevate the issue with the documentation and communication to the insurer’s Medical Director or higher to remove any obstacles.

It is important to remember that persistence pays, and knowledge paves the way.

References

Aetna Better Health of Pennsylvania. n.d. Case management. Accessed July 19, 2021. https://www.aetnabetterhealth.com/pennsylvania/health-wellness/case-management.

Anthem Blue Cross. 2015. COMPLEX CASE MANAGEMENT & DISEASE MANAGEMENT GUIDELINE WORKBOOK. Accessed July 30, 2021. https://www11.anthem.com/ca/provider/f1/s0/t0/pw_e171273.pdf?refer=provider.

Blue California. n.d. Accessed July 30, 2021. https://www.blueshieldca.com/bsca/bsc/wcm/connect/sites/sites_content_en/bsp/providers/programs/complex-case-management.

Central California Alliance for Health. 2021. Complex Case Management and Care Coordination. July 15. Accessed July 30, 2021. https://thealliance.health/for-providers/manage-care/clinical-resources/care-management/complex-case-management-and-care-coordination/.

Cigna. n.d. Case Management. Accessed July 30, 2021. https://www.cigna.com/health-care-providers/resources/case-management.

Health Care Support. n.d. Managed Care & Commercial Insurance Complex Case Manager Nurse. Accessed July 19, 2021. https://www.healthcaresupport.com/complex-case-manager-nurse/.

healthinsurance.org. n.d. Reinsurance. Accessed July 30, 2021. https://www.healthinsurance.org/glossary/reinsurance/.

NCQA. 2009. Special Needs Plans – Structure & Process Measures. March 30. Accessed July 30, 2021. https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/Downloads/SPMeasuresUpdate.pdf.

About the Author:

Reginald (Reggie) Allen, MBA, RN serves the mission of CHRISTUS Health as Chief Operating Officer of CHRISTUS Spohn Hospital Corpus Christi – Shoreline and Memorial. Using his clinical and business knowledge as well as experience gained during his 30+ years in health care, he is responsible for care design and delivery across the continuum of care employing up-to-date evidence based medical protocols and guidelines. In addition, Reggie incorporates a wide variety of quality tools in his clinical redesign and implementing evidence-based guidelines and protocols for his south Texas community.

Reggie has received national and state-level recognition for his work in resource management and clinical operations which includes case management, revenue cycle, clinical appeals, compliance with federal and state regulations, and implementation of quality improvement processes in both clinical and business arenas. He clearly understands the relationship between clinical quality variances and negative financial impacts.

Reggie gained much of his expertise and prospective from his early work as a staff nurse in a variety of specialties and serving for-profit and not-for-profit hospital systems in various roles such as Director of Nursing, Chief Nursing Officer and Chief Operations Officer. He was an independent health care consultant prior to joining CHRISTUS Health in 1999.

He is a member of the American Case Management Association (ACMA), American College of Healthcare Executives, and Healthcare Financial Management Association. He is on the editorial board for ACMA.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

July 2021

Next Complimentary Webinar!

The Power Behind Standards of Care in Successfully Appealing Medical Necessity Denials

Wednesday, September 15th | 2PM – 3PM Eastern Time

Presenters: Denise Wilson, MS, RN, RRT, Senior Vice President, Intersect Healthcare + AppealMasters & Kendall Smith, MD; Chief Physician Advisor, Intersect Healthcare + AppealMasters

Free CEUs for our AHDAM Members!

Click here to register!

Medicare’s Shared Visits and the Proposed 2022 Physician Fee Schedule

By David M. Glaser, Esq.

Shareholder Fredrikson & Byron

On May 3rd CMS deleted the language found at Medical Claims Processing Manual Chapter 12, Section 30.6.1 that created “shared visits”. Shared visits allow a physician to bill for the combined work of a physician and a non-physician practitioner when both professionals see the patient in an outpatient or inpatient hospital setting. That may sound like the “incident to” benefit. In fact, it is easy to be confused about how Medicare differentiates between services that are considered “incident to” and shared visits. There is a good reason for the confusion. Medicare sometimes used the two terms interchangeably. Moreover, shared visits seem like a subset of incident to encounters. But there is a reason “shared visits” were created; the incident to benefit is generally not available in the hospital.

Medicare has a regulation, 42 CFR 411.15(m), that specifically excludes a variety of services to hospital patients. Included in the list of services that are not covered in the hospital are “services incident to a physician service.” In other words, a physician can’t bill for services incident to the physician’s work when they are done in the hospital, either inpatient or outpatient. (If this weren’t confusing enough, Medicare routinely refers to a wide variety of hospital services as “incident to.” Unfortunately, the same term has been used multiple times with a different meaning. But when CMS is talking about hospital services incident to, they are talking about services covered by the facility fee, not professional services. This is terribly confusing, but also a topic for another day. For our purposes we are discussing services both performed, and billed, by a physician.)

To solve that problem Medicare created “shared visits.” Unfortunately, rather than issuing a new regulation, CMS did this via the Claims Processing Manual. The government has increasingly recognized that only statutes and regulations can limit Medicare coverage, so when something in the Manuals is not contained in either a federal law or a federal regulation, it is not binding. CMS has created a mechanism permitting people to request deletion of Manual language that is not based on a regulation, and someone submitted a request noting that the absence of a regulatory discussion about shared visits, prompting CMS to delete the text. Section 30.6.1, which used to contain the discussion about shared visits, now says “Left intentionally blank for future updates.”

July 13th, CMS issued the proposed 2022 Physician Fee Schedule. It is merely a proposal, with the final rule to be adopted sometime in late October through early December. The proposed rule would incorporate shared visits into the federal regulations.

The proposal presents a revisionists history of the old manual provision. The deleted manual language said that a shared visit was possible when the physician “provides any face-to-face portion of the E/M encounter with the patient.” The preamble to the proposed regulation instead says that the old policy was that the physician had to provide a “substantive portion” of the visit. That is simply untrue. There was a discussion about “substantive portions” of a visit, but it appeared in 30.6.13, a section about nursing facility services. That section explains that shared visits are not covered in skilled nursing facilities. I went years without knowing that the discussion in 30.6.13 existed, and for good reason. If you are trying to find out how shared visits in the hospital work, once you found 30.6.1, which defines “shared visits” you would end your research. You wouldn’t continue to pour through the Manual looking for additional sections, and you certainly wouldn’t devote any time to reading a section discussing visits in skilled nursing facilities, particularly when that section opens by declaring that shared visits can’t be covered in that setting.

Under the now-deleted manual language, if the physician walked in and said, “how are you doing?” to the patient, thereby obtaining some history from the patient, it was appropriate for the physician to bill a shared visit. That is similar to the operation of the “incident to” benefit in the clinic. When billing “incident to” when the physician and non-physician practitioner both see the patient on a day, that is sufficient to allow the physician to bill. There is no expectation that the physician spends the most time with the patient. In fact, as long as the physician in involved in the care, there is no minimum threshold the physician must satisfy.

However, the proposed regulation would make time determine who may bill for a shared visit. Under the proposal whoever records the most time on the visit will bill. This is a terrible idea. An experienced physician can offer meaningful advice quite quickly. Wisdom and time are different. Under the proposal, if a physician has a 20-minute conversation with the patient and an NP, but then leaves the room, and the NP spends one additional one minute with the patient, the physician is not allowed to bill for their work. Under the proposal, the total time of 41 minutes spent by the two professionals would be compensated as 21 minutes of NP time. That is not a fair result. The proposal would create a bizarre irony: more time the two professionals devote, the more uncompensated care professionals are providing. For a complicated patient requiring more time of both the physician and the non-physician, a lower percentage of their work would be compensated.

The proposal also contains an explicit requirement that the billing professional sign the entry. Historically there has not been a signature requirement for Medicare encounters. In short, the proposal makes things much worse than they were before. Under a proposed rule you get time to comment. I recommend that we inundated CMS with comments suggesting that the regulation take a different approach. In particular, the regulation should follow the model from the Manuals. If the physician and a non-physician practitioner both see the patient on a day, their work is combined into one bill, which may be submitted under the physician. The relative time spent by each should not determine who bills. The proposal to require a signature should be deleted. The idea that a service should be denied because of a missing signature is contrary to the admirable effort CMS has been making to avoid hyper-technical denials.

Until the final rule is adopted, what does one do? I wish I could give a 100% guarantee that you can use the principles articulated in the deleted shared visit language without fear of retribution. While I can’t, I would still use those principles. At least one Medicare administrative contractor, WPS, explicitly said they are still allowing shared visits. But the main reason that I would continue to use the “shared visits” principles is that they seem logical, and I don’t believe that they are explicitly prohibited by any statute or regulation. There is a longstanding principle that when two or more professionals of the same specialty see a patient in the same day, only one E/M services is billable. Nothing in the statutes or regulations PROHIBITS the idea that the work of the two professionals may be combined. Because of 42 CFR 411.15(m) we can’t say that the visit is “incident to,” but we can still argue that we are still applying the longstanding principle of combining visits by two professionals in the same specialty into one bill. Therefore, I would be inclined to bill using the principles outlined in the deleted Manual language. In the event that the claim is denied, you have a reasonable basis for appeal.

The other option, of course, is to bill the service under the name and number of the non-physician practitioner and await the final fee schedule.

About the author

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

June 2021

Leveraging ADT, HL7 Data May Help Hospitals Prevent Denials

You think you know Medicare medical policy requirements? What about Medicare Managed plans? Use your ADT data sets and payer policies to stop denials at their source. Check out this new article by Nina Youngstrom from the Report on Medicare Compliance with input from Kendall Smith, M.D., Chief Medical Officer of Intersect Healthcare + AppealMasters, and Tracey Tomak, Area Vice President of Intersect Healthcare + AppealMasters. You can find it on our homepage at www.ahdam.org.

BFCC-QIOs, Higher-Weighted DRGs, Medical Necessity, and Appeals

By Denise Wilson, MS, RN, RRT

President AHDAM

There has been some discussion in the denial and appeal community regarding BFCC-QIOs, higher-weighted DRGs, and medical necessity, so I thought I would take a moment to provide some education. Let’s start by understanding higher-weighted DRGs (HWDRGs).

Higher-Weighted DRGs

CMS allows hospitals up to 60 days to rebill an inpatient Part A claim with a DRG different than what was initially billed. This happens when additional information, such as a response to a coding query, for example, warrants a change in coding. That change in coding may result in a higher-weighted (higher-paying) DRG being assigned to the inpatient claim. Once the higher-weighted DRG has been accepted by the Medicare Administrative Contractor (MAC), the claim undergoes review by the QIO.

Per the Code of Federal Regulations, 42 CFR 476.71(c)(2), CMS’s Quality Improvement Organizations (QIOs) “must review changes in DRG and LTC-DRG assignments made by the intermediary…that result in the assignment of a higher-weighted DRG or a different LTC-DRG.” Besides reviewing the HWDRG claim for accuracy of the coding, the QIO is also instructed to perform a medical necessity review and a quality-of-care review. So, once a higher-weighted DRG has been submitted to the MAC, the claim is opened to review for DRG validation, medical necessity, and quality of care. The process is outlined in the CMS Quality Improvement Organization Manual, Chapter 4, part 4050.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/qio110c04.pdf

Beneficiary Family Centered Care Quality Improvement Organizations (BFCC-QIOs)

CMS has two QIOs so that medical case review work is separate from quality improvement work. BFCC-QIOs perform medical case reviews. Quality Innovation Network Quality Improvement Organizations (QIN-QIOs) perform quality improvement work.

Livanta, LLC, is the contractor that was recently awarded the nation-wide contract for performing medical case reviews including HWDRG reviews. Livanta announced on April 27, 2021, that they were awarded the national contract. Prior to that, the work was done by both Livanta and KePro, another BFCC-QIO who held a contract with CMS. Acute Care Facilities, including acute care inpatient hospitals, inpatient psychiatric hospitals, and long-term acute care (LTAC) hospitals must sign a Memorandum of Agreement with Livanta if you do not already have one on file. You must do this to establish an administrative relationship with Livanta for the exchange of data and information. https://livantaqio.com/en/ClaimReview/MOA/moa.html

Livanta states on it’s website, “Inpatient hospital payment adjustments that have been processed by the Medicare Administrative Contractors (MACs) and result in higher-weighted DRG assignments are reviewed by Livanta to ensure that the diagnosis and procedure codes reported are supported by the documentation in the medical record. These cases also undergo review to determine if the services meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting.” https://www.livantaqio.com/en/Provider/Case_Types

The QIO notifies the provider of their unfavorable review decision within 30 days of the decision.

Medical Necessity

Although I don’t believe it happens very often, it is possible that a HWDRG claim that is reviewed by the QIO will be denied for medical necessity. In fact, I have seen it happen. When the QIO review the HWDRG claim and determines that the higher-weighted DRG is not appropriate for the claim, the claim is paid at the original DRG or the DRG that the QIO has determined is appropriate. When the QIO review of the HWDRG results in a denial for medical necessity of the inpatient admission, the entire payment amount will be denied. This is the same as when an inpatient admission denial is issued by any CMS auditor.

Appeals

Denials that occur from a QIO review are appealable. But the appeal process is brief and for HWDRG claims, it does not follow the more-familiar 5-level Fee for Service Medicare appeals process. According to 42 CFR 476.93, “Before a QIO reaches an initial denial determination or makes a change as a result of a DRG validation, it must—

(a) Promptly notify the provider or supplier and the patient’s attending physician (or other attending health care practitioner) of the proposed determination or DRG change; and

(b) Afford an opportunity for the provider or supplier and the physician (or other attending health care practitioner) to discuss the matter with the QIO physician advisor and to explain the nature of the patient’s need for health care services, including all factors which preclude treatment of the patient as an outpatient or in an alternative level of inpatient care.” So, the discussion period is available to providers for both proposed DRG changes and denials for inpatient admission. QIOs are to allow the providers 20 calendar days for oral or written discussion of the decision. Not a lot of time!

After the discussion period, the QIO issues their final decision for DRG assignment, the decision is not subject to reconsideration and further appeals. However, the final decision is subject to a re-review when the revised DRG assignment resulted in a lower payment.

After that, the provider can request a re-review. A written request for re-review must be filed within 60 days after receiving notice of the coding change. The QIO has 30 days to respond with a written notice of their decision within 30 working days. After that, there are no more opportunities to appeal.

If the HWDRG review resulted in a denial for medical necessity, a written request for a reconsideration can be filed to the QIO within 60 days. The QIO has 30 days to respond. After that, an appeal can be filed to the Administrative Law Judge hearing (level 3 appeal). The fourth and fifth appeal levels are available if the outcome from the hearing is unfavorable. CMS Quality Improvement Organization Manual, Chapter 7 – Denials, Reconsiderations, Appeals. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/qio110c07.pdf

Summary

CMS named Livanta the national BFCC-QIO in April 2021. Livanta will be performing all HWDRG reviews for CMS. Be sure your facility has an MOA on file with Livanta. If the QIO reviews a claim for HWDRG, they also review the claim for medical necessity and quality issues. If the claim is denied for the HWDRG, there are only two opportunities to reverse the decision – a discussion and a re-review. If the claim is denied for medical necessity or quality issues, the provider can appeal for a reconsideration and then continue through the 5-level Medicare appeals process.

Next Complimentary Webinar!

The Road to External Review

Wednesday, July 14th | 2PM – 3PM

Many denial and appeal management specialists are not aware that there are often opportunities to continue an appeal outside of the payer’s internal appeal process. Join us to learn how to move an appeal to an external review where the best opportunity for overturn exists.

Learning Objectives:

Determine whether a denied claim has the option of being filed to external review.
Identify the primary state and the primary federal organizations that describe the steps for taking an appeal to external review.
Explain how to research state external review processes in the learner’s state.

Presenters: Denise Wilson, MS, RN, RRT, Senior Vice President, Intersect Healthcare + AppealMasters and Bill Haynes, Esq. Managing Attorney, Intersect Healthcare + Denial Research Group

Free CEUs for our AHDAM Members!

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DISCLAIMER

May 2021

AHDAM Celebrates One Year in Existence!

Thank you to all of our members who have begun renewing their memberships. We’ve heard some terrific feedback from members who are excited to continue their membership in AHDAM. If your membership is expiring soon, you will receive an email with a reminder to renew. Remember we have group memberships available at a discounted rate. Gather up your coworkers for a group membership so they can take advantage of the same great benefits you enjoy. Contact us at [email protected] or 410-321-4690 with any questions about or assistance with memberships.

Our Next Complimentary Webinar!

The CDI and Coding Team Approach to Audits and Denials: The Best Defense is a Good Offense
Wednesday, June 16th | 2PM – 3PM Eastern
Free CEUs for AHDAM members only.

Summary:

The best approach to successful denials/appeal management is a proactive methodology incorporating a multidisciplinary team. Focus on a solid educational foundation, robust prevention tactics, and a well-developed process for data analysis to find success. Denial and appeal mitigation teams must be armed now to address denials that are evolving into a broad spectrum of denial rationales. Learn from our subject matter experts how to engage in a multidisciplinary approach to denials management that incorporates both reactive and proactive strategies.

Learning outcomes:

1. Identify the main types of audits and denials.
2. Identify 2 of the benefits of close CDI/Coder collaboration.
3. Identify 3 specific strategies that clinical and revenue cycle professionals can adopt to support denials management.

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First Lines of Defense in Appeal Writing

By Denise Wilson, MS, RN, RRT

President AHDAM

When it comes to defending against denials and unfavorable audit outcomes, there are several steps a denial and appeal management professional can take as a first line of defense. These steps mostly involve ensuring that the auditor or payer is correct in their decision and that they have followed regulatory and contract rules in issuing a denial.

Denial correspondence is very often lacking in denial specificity, explanation simplicity, and plan provision applicability. There are rules regarding what information a payer must provide to the plan participant. ERISA, for example, requires the plan provide the reason for the denial in a manner that can be understood by the participant (https://www.law.cornell.edu/uscode/text/29/1133). ERISA is The Employee Retirement Income Security Act of 1974 that establishes minimum standards for health plans provided by employers in private industry. ERISA plans must provide specific reasons for the denial, reference to plan provisions, a description of the plan’s review procedures and time limits, and a statement of the rule, guideline, protocol or other criterion used in making the decision (among other things). If the rule, guideline, protocol or other criterion are not provided with the denial, it must be provided free of charge upon request (https://www.law.cornell.edu/cfr/text/29/2560.503-1).

Determining whether the payer has provided all required and necessary information regarding the denial is a first line of defense. If they haven’t, and time allows prior to filing the appeal, request the information in writing if possible. It does no good to take a stab at what the denial reason might be because you only end up wasting a level of appeal.

Once you have obtained the criterion on which the denial was made, ensure that the criterion was active at the time the medical services were provided. The Official Coding Guidelines are published annually, and Coding Clinic issues are published quarterly. If the denial is a coding issue, did the payer use guidelines that were current for the dates of service in question? For clinical validation denials, ensure the guideline was published prior to the patient’s hospitalization. Although there is no hard and fast rule for when a new diagnostic guideline becomes valid for use, common sense dictates that some time should pass to allow clinicians to read, digest, question, validate, and incorporate diagnostic guidelines into practice. Believe it or not, clinical validation denials were issued for not meeting Sepsis-3 criteria for claims where the patient was hospitalized on the day the Sepsis-3 criteria were published. No provider should accept that as an appropriate payer auditing practice.

The same could be said of clinical practice guidelines published by physician professional societies. Clinical practice guidelines are typically updated every 5 to 10 years. Some time must be allowed to pass before physicians begin to incorporate any major change in care guidelines into their practice. Commercial payers typically update or at least review their clinical policy bulletins annually. Medicare’s national or local coverage determinations don’t typically follow a strict timeline for review but are updated as medical practices change. Take note of the effective date of a Commercial payer’s clinical policy bulletin or Medicare’s national or local coverage determinations. Did the payer cite the guideline that was in effect at the time services were rendered? Did those guidelines truly represent the standard of care at the time services were rendered?

Let’s take this concept in the other direction. What if the clinical policy bulletin or coverage determination is out of date and doesn’t represent the current standard of care? Many pacemaker insertions were denied payment by Medicare a few years back based on a national coverage determination that did not represent the current standard of care. So, the guideline argument can go both ways; is the recommended practice too new or too old? Validating the use of an appropriate guideline by the payer to issue a denial is a first line of defense.

What do your contracts with your payers state as far as utilization management and auditing practices? Are your commercial payers following the practices outlined in your contracts? Are they following agreed upon timeframes and issues for auditing your claims? Denial and appeal management professionals must hold the payers accountable for following the rules in the same way that payers hold providers accountable.

Finally, are the reasons given by the payer for the denial true and factual? If not, refute the inaccurate statements early in the appeal. Be specific. If the payer states the patient’s body mass index (BMI) was not documented, but the medical record includes the BMI, point that out in the argument. That way when a pattern of inappropriate denials is identified that pattern can be presented to the payer objectively. The first rule in denial and appeal management is never assume the payer’s reason for denial is correct.

So, before putting pen to paper or fingers to keys to draft that appeal letter, take the time to look at your first lines of defense. You might be surprised how often you find an objection to a payer’s denial process that should be used as a powerful opening statement in the payer-provider conversation that is the appeals process.

Appeals Shortcut – Orthopedic Surgery

Be sure to check out our newest posting in the Knowledge Center. R. Kendall Smith, MD, SFHM Chief Physician Advisor, Intersect Healthcare, provided a short, self-guided presentation on appealing a denial for shoulder arthroscopy. Learn how you can effectively appeal a medical necessity denial when physician office notes are missing or incomplete.

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

April 2021

AHDAM Celebrates One Year in Existence!

The Association celebrated it’s one year anniversary on April 15, 2021! It’s been a joy and pleasure to build this association with all of you. Membership has grown past our expectations which reinforces that there is a need for a denial and appeal community. We’re looking forward to adding more resources, more education, and more collaboration in the coming year. Thank you for being an inaugural member!

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Benefit corporations use business as a force for good. They meet a higher standard of accountability and transparency. They unlock the full human potential and creativity to use the power of business for the higher purpose of solving society’s most challenging problems.

Benefit Corporations are required by Maryland law to publish an annual report. You can read about how AHDAM has created a general and a specific public benefit over the past year. Find our report under the About page on the www.ahdam.org website.

When is a Clinical Validation Audit Not Valid?

By Denise Wilson, MS, RN, RRT

President AHDAM

Obesity

Recently, on behalf of AHDAM, I provided educational webinars on denials and appeals related to coding obesity and BMI. The webinars were presented to members of local AHIMA chapters. In reviewing the actual denial and appeal examples I used in my presentation, it occurred to me that questioning the clinical validity of obesity would seem like a losing proposition for payers. Coding clinics are pretty clear about when obesity or morbid obesity can be coded. “Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider[1].” And yet I had in front of me several examples of payers questioning the validity of including an obesity code on a claim. One payer actually treated it as a clinical validation denial:

“The patient’s BMI was 43.7. No record was found in the chart of a plan for weight loss or specific treatment related to morbid obesity. No obstacles to treatment were documented that related to body habitus. From a clinical validation perspective, coding BMI 40.0-44.9 and Morbid (severe) obesity was not justified in this case.”

First of all, I don’t see how a plan for weight loss or specific treatment for the obesity would be considered clinical indicators of the disease. Yes, I often say that treatment of a diagnosis helps support the clinical validity of the diagnosis, but first you have to have documented clinical indicators of the diagnosis for the diagnosis to be valid.

So, if an obesity code were ripe for auditing for clinical validity, what clinical indicators would we expect to see outside of weight or BMI? Maybe documentation of body habitus? Documentation of waist circumference, waist-to-hip ratio, skinfold thicknesses, or bioelectrical impedance? None of these methods are easily or readily performed in a hospital setting. I just don’t see how obesity can be assessed from a clinical validation standpoint, except by looking at the patient’s recorded weight or BMI. And I don’t understand why a payer would try to audit the diagnosis code from a clinical validation standpoint when coding guidelines give clear direction that obesity is always clinically significant.

COVID-19

The other diagnosis code that I feel falls into a similar category is the code for COVID-19, U07.1. Coding guidelines are clear on this one as well. “Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider, or documentation of a positive COVID-19 test result. For a confirmed diagnosis, assign code U07.1, COVID-19. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of a positive test result for COVID-19; the provider’s documentation that the individual has COVID-19 is sufficient.”[2]

I was asked this question recently from an AHDAM member:

“U07.1 was coded as a secondary diagnosis based on a positive test during admission. However, the U07.1 code was removed by the payer following an audit of the record. The treating physician had noted in the record that the patient was not infected, the test was false positive due to the patient’s history of previous Covid infection or any other documentation which states the patient does not currently have Covid. Should we use the coding guideline as evidence that U07.1 should not be removed and appeal? Or based on the additional documentation that the patient does not have Covid, should we accept the removal of the U07.1 code?”

I would definitely appeal. My impression is that the seemingly lax rule for the use of U07.1 was an attempt by the CDC to record all cases of COVID-19 during the pandemic. Will coding rules become stricter in the future and require some clinical correlation? Possibly, but remember that there have been cases of asymptomatic COVID-19 infections which just complicates the entire situation. I understand that a physician may document his assessment that the test might be a false positive and the patient has recovered. His or her assessment is necessary and required to fully document the current health status of the patient. However, as long as coding guidelines tell us to code COVID-19 with a positive test result, I believe that’s what we should be doing.

[1] Clinical Significance of Obesity, Coding Clinic, Third Quarter 2011 Page: 4, Effective with Discharges: September 23, 2011

[2] https://www.cdc.gov/nchs/data/icd/ICD-10cmguidelines-FY2021-COVID-update-January-2021-508.pdf

Appeals Shortcut – Orthopedic Surgery

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

March 2021

Upcoming (Free!) AHDAM Webinar with CEUs for AHDAM Members

Join us Wednesday, April 7, at 2:00 p.m. Eastern Time for AHDAM’s free webinar, Clinical Legal Partnerships to Overturn More Denials. Brian McGraw, President, Intersect Healthcare and Denial Research Group and Dr. Kendall Smith, Chief Physician Advisor, Denial Research Group/AppealMasters will be presenting on the important partnership between clinical and legal teams for a two-pronged attack against denials. Attend this webinar to learn your legal protections against egregious payer behaviors. Although anyone can attend this 60-minute webinar, AHDAM is offering free CEUs to AHDAM members only. One CEU credit is available through NAHRI, ACDIS, and The Commission for Case Manager Certification for case managers. Application for one CEU credit has been made to AHIMA. This activity has been submitted to the Northeast Multistate Division for approval to award contact hours. The Northeast Multistate Division is accredited as an approver of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. You can find out more on the website homepage www.ahdam.org. You can register here: COVID-19 Webinar.

The Road to External Review

By Denise Wilson MS, RN, RRT

AHDAM President

Levels of Appeal

If you’re like me, you grew up in the appeals world referring to every filed appeal by its level name. The first appeal was the Level 1 appeal. The second appeal was the Level 2 appeal and so on. Identifying appeals by their level name still has its place in the appeal world. The appeal level signifies how many times the provider has appealed a denial to the insurance company. However, communication about appeals is more explicit when we use terminology that describes the appeal by the payer’s name. If the payer calls the first level appeal a reconsideration, the appeal writer should use the word reconsideration in the letter’s body. If the payer refers to the first appeal filed as a review, the writer should use the word review. Using payer-specific terminology decreases the payer’s opportunity to dismiss the appeal as a duplicate or a non-valid request for appeal.

I want to make another recommendation for the correct naming of appeals. All appeals filed to the auditor or the payer should be called internal appeals. We use the word internal to mean the appeals process set up internally by the payer. External review is a general term referring to the filing of an appeal to any agency outside of the payer or auditor. External review agencies review the appeal and accompanying documentation and make an independent decision to overturn or uphold the denial. The decision is independent because the external review agency is separate from the payer.

For traditional Medicare, the external review starts with the Qualified Independent Contractor (QIC). Appeals filed to the QIC are typically the second appeal filed by the provider and referred to as Level 2 appeals. Commercial payers’ external review agency is called an Independent Review Organization (IRO) or Independent Review Entity (IRE), or some other name. We should get in the habit of referring to our appeals as internal or external. The reason for delineating between the two is that providers report a higher overturn rate at external appeal. Knowing that a denial was overturned at internal or external appeal provides valuable insight into payer behaviors.

When does external review come into play?

The Patient Protection and Affordable Care Act, Public Law 111-148, enacted on March 23, 2010[1],[2], ensured that patients are guaranteed the right to file for external review as a consumer protection standard. However, for providers, the opportunity to file for external review depends for the most part on the payer and other factors. For traditional Medicare, as previously mentioned, external review for provider appeals is always available and occurs at the QIC. For commercial payers, including managed Medicare, external review availability for providers depends on the insurance product, the payer-provider contract, or lack of contract, the payer’s provider manual, and state law.

When a provider is not contracted with a Medicare Advantage organization and a reconsideration (level 1) appeal is upheld, the appeal advances automatically to an independent review entity for the second level appeal. Per the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, “All partially favorable or adverse reconsideration decisions are forwarded to the IRE. A party does not have to make a request for a level 2 appeal.” So, similar to the traditional Medicare appeals process, the appeal moves to external review at the second appeal. However, the provider or patient who filed the first level appeal does not have to file to the IRE. The MAO is required to advance the appeal automatically to external review[3].

New York state allows providers appealing commercial claim denials to request an external appeal when there has been a retrospective adverse determination on a claim. Certain restrictions apply, such as the denial must have been issued because the services were not medically necessary or deemed experimental or investigational. Also, the internal appeal process must be exhausted first in most cases before filing for external review. Not all states allow providers to file directly for external review. Most states allow providers to file for external review on behalf of the patient as the patient’s authorized representative. If the patient’s appeal is successful, the provider receives appropriate payment. There is usually a cost associated with filing for external review. Suppose you aren’t pursuing external review when it is available. In that case, it is worthwhile to work with a legal team member to discover the available avenues to move your appeal outside the court of the payer’s opinion.

[1] https://www.cms.gov/CCIIO/Resources/Files/external_appeals

[2] https://www.hhs.gov/healthcare/about-the-aca/cancellations-and-appeals/appealing-health-plan-decisions/index.html

[3] https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Managed-Care-Appeals-Flow-Chart-.pdf

Top Tips for Successful Clinical Validation Appeal Arguments

Check out the latest article published in the Knowledge Center on the www.ahdam.org website. Breen Nabors, RN, CCDS shares tips for writing a successful clinical validation appeal letter and bravely uses Sepsis as the example!

AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

February 2021

Upcoming (Free!) AHDAM Webinar with CEUs for AHDAM Members

Denials and Appeals: The Devil is in the (Contract) Details

By Taryn Schraad, Compliance Consultant

AHDAM Advisory Board Member

Healthcare providers know all too well of the heart-breaking stories behind payer claim denials. Stories of insurance plans rejecting payment for services related to unavoidable readmissions, complicated health conditions, service levels, or evolving disease processes. Health plans deny inpatient stays as “not being medically necessary” or “invalid diagnoses,” leaving providers with the task of justifying treatment and care beyond medical record documentation to receive payment for appropriate care.

Over the years, it has become apparent that health plan claims denials cause considerable revenue leakage and accounts receivable backlog for healthcare providers. Change Healthcare [1] analyzed 2016 claims data which revealed that out of an estimated $3 trillion in medical claims submitted by U.S. hospitals, an estimation that 9% of those charges, representing $262 billion, were initially denied. That equates to 3.3% of net patient revenue or $4.9 million per hospital. The administrative costs of writing and managing appeals are significant and cost providers roughly $118 per claim.

Ambiguous contract language and payment terms regarding appeals processes only add salt to an already open wound of arduous appeals. The complex layers of a denial and appeal process pit payers and providers in different corners and perspectives for delivering treatment and level of care. While providers can use analytics to identify the root cause of denials and improve revenue cycle workflow, evaluating contract language and negotiating better audit, appeal, and care coordination terms could level the playing field a bit more.

Payer contracts often fail to address a clear plan and workflow for handling denials and appeals, including how to mitigate issues that disrupt and delay payment. Providers should set boundaries to control aggressive audit, denial, and appeal behavior. Guarding the gates of patient care delivery and payment may reduce the burden of appeals and the number of auditors and audit contractors accessing patient medical records.

Here are few suggestions that organizations should consider when negotiating the contract structure to address denials management solutions.

Allow the payer to conduct presumptive authorizations of same-day and ER-to-inpatient admissions with access to the medical record, thus eliminating pre-authorization and lending support to service level denials.
Request that like specialists conduct peer-reviews so your providers discuss patient treatment plans with peers who are familiar with evidence-based clinical guidelines.
Clearly outline the clinical criteria used, the state and federal regulations applied, and what policies will determine care levels. Highlight distinctions and discrepancies between payer, federal, and state guidelines and the process to remediate those issues.
Define “readmissions” and how federal and state regulations apply, including various patient factors that may impact a readmission timeline. Understanding your patient base’s medical needs allows the provider and payer to negotiate a fair and realistic readmission coverage process.
Request consistent payer reports that track and trend denial analysis for comparison to in-house denial and overpayment data.
Request that denials be placed on hold for a specified period when overturns are high, and denial percentages are low, giving the provider a break from the deluge of audits.
Establish concrete appeal and response timeframes, including audit cancellations for appeal responses that exceed a deadline.
Be aware of dispute resolution time frames and associated costs and seek the ability to bundle cases for arbitration.
Mandate a payer/provider coordinated case management program to establish a continuum for managing complex patient cases after the discharge, ensuring the payer also follows up with chronic and critical beneficiaries.
Require all payer and third-party medical record requests follow state medical record release timelines, medical record formats and media (electronic, portal submission, DVD, facsimile, paper, etc.) according to providers capabilities, including appropriate timeline extensions if necessary.

Providers should track payer contention areas from admission to discharge then develop statements and solutions that can integrate into payer contracts during negotiations. Contract statements and equitable solutions can be valuable resources should the provider file a grievance against a payer for erroneous denials and excessive and burdensome appeal processes.

Finalizing the payer contract details allows organizations and payers to establish clear-cut communication methods detailing the processes, timelines, and expectations from both parties within the contract language. Setting a fair and equitable workflow will make the lives of everyone involved in the audit, denial, and appeal process easier. Ultimately, setting the guidelines of audit, denial, and appeal methods may also benefit the patient by shielding them from the logistics and laborious process of appealing their own uncompensated healthcare services.

About the author

[1] Hanson, S. (n.d.). 6 steps that can capture more revenue for your hospital. Retrieved February 22, 2021, from https://www.changehealthcare.com/insights/capture-more-revenue

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AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

January 2021

Hello 2021

Let’s name 2021 the year of recovery and then do everything we can to make it live up to its name. Our hope is that 2021 will be a year of rest, recovery, peace, and a return to some sense of normalcy for our heroes in healthcare.

Upcoming (Free!) AHDAM Webinar with CEUs for AHDAM Members

Join us Wednesday, February 17, at 2:00 p.m. Eastern Time for AHDAM’s free webinar, COVID-19 Denials and Appeals. Denise Wilson, President of AHDAM and Senior Vice President at Denial Research Group | AppealMasters and Dr. Kendall Smith, Chief Physician Advisor at Denial Research Group | AppealMasters will be presenting on managing denials for COVID-19 care in the inpatient and outpatient settings. This webinar will cover coding, clinical validation and medical necessity denial issues and appeal strategies related to the care of persons with COVID-19. Although anyone can attend this 60-minute webinar, AHDAM is offering free CEUs to AHDAM members only. You can find out more on the website homepage www.ahdam.org. You can register here: COVID-19 Webinar

The Journey from Observation to Inpatient

By James Haering, DO, SFHM, CHCQM

AHDAM Advisory Board Member

Background: it is no surprise that Medical Necessity (MN) denials often focus on short inpatient hospital stays[1], stays of 3 days or less. This is especially true for encounters converted from observation (OBS) services to inpatient status (IPS). By their very nature, this population has a lower severity of illness, having failed to meet IPS criteria during the initial review by the hospital Utilization Management (UM) team.

What types of medical patients are hospitalized initially with observation services and subsequently converted to inpatient status? The idealized scenario is a single, acute, low-risk condition (e.g., chest pain), that after testing has findings warranting the conversion to IPS. However, we often encounter three other patient populations:

The chronically ill, with multiple comorbidities, and lacking severity of illness to meet IPS criteria. These comorbidities often confound the evaluation and treatment. E.g. Needing to reverse anticoagulation before performing an invasive procedure.
Patients with significant psychosocial issues that impact the post-discharge care plan. A prudent clinician would be concerned that outpatient care would fail. E.g. a homeless man with cellulitis and noncompliance with his medications.
Those with shifting problems, e.g., chest pain on day one, hypertension on day 2, and hypokalemia on day 3. Individually, these issues fail to meet the severity of an inpatient status. Yet, after multiple days of OBS, the patient still requires active management and monitoring.

It is often difficult and frustrating to use standardized MN criteria sets when confronted with patients too sick to go home but not sick enough to warrant IPS. These patients:

Frequently start under an order for OBS.
Remain hospitalized longer than we would like.
Are a target of payors, who may deny a conversion to IPS.

We should not simply accept that a large percentage of these patients will languish in OBS, or that payors are right in denying these conversions from OBS to IPS. Let us dive deeper into successful strategies for the patient transitioning from OBS to IPS

Whether you are performing concurrent reviews, preparing for a peer-to-peer with the insurance provider, or constructing an appeal of a denied IPS encounter, it is recommended that you develop a consistent approach to the record review. The following tips and techniques are designed to focus your efforts, increasing the likelihood of a positive outcome. In this article, we will look at the three questions, three events, and three ‘don’ts,’ when looking at the MN of converting from OBS to IPS, but first, we need to understand the concept of predictable risk.

PREDICTABLE RISK

When determining the medical necessity of services, the reviewer needs to consider the likelihood, or potential for negative outcomes, if the service is not provided. Regardless of the terms use, providers need to predict the risk of adverse events with outpatient management when deciding if hospitalization is warranted. In general, those converting from OBS to IPS may have few classic objective measures of illness, such as abnormal labs or vitals. They often appear clinically less ill than those initially admitted as IPS. In this population, most denials are focused on the lack of these objective findings.

In framing the appeal, it is useful to look at the case from the opposite direction, and ask “If I send them home, what could go wrong, and how likely is it to happen?” In some cases, we have accepted criteria such as the Pneumonia Severity Index, which can calculate the risk for us. Most of the time, we do not, and we need to rely on clinical decision-making and sometimes common sense.

For each of these scenarios, consider if the patient is at low or high risk of complications and what risks are posed with outpatient management.

Simple pneumonia in a 52-year-old with Pneumonia Severity Index class II, and
- no comorbidities, residing at home with family, easy access to the patient antibiotics, and close follow-up with his primary care physician.
- Homeless, without transportation or access to outpatient antibiotics, noncompliant with medical therapy, substance abuse, no PCP, and poorly controlled psychiatric issues.
Syncope
- 22-year-old with no comorbidities who passed out during a wedding and with a normal ED evaluation.
- 84-year-old with chronic systolic heart failure, chronic hypoxic respiratory failure, end-stage renal disease, seizure disorder, previous stroke, and not on anticoagulation.
Non-surgical fracture of the right humerus
- 66-year-old with stable hypertension, and controlled DM 2, residing at home with family, and a normal ED evaluation.
- 89-year-old residing at home alone, who utilizes a walker due to postpolio syndrome affecting her right lower extremity, and previous stroke with residual deficits of the left upper and lower extremity. She has contraindications to NSAIDs and previous adverse effects when taking opioids.

If a reasonable clinician reviewing the case can deduce an increased risk of an adverse event occurring with outpatient management, then hospitalization may be supported. Ideally, the treatment team has documented their clinical concerns and the risks of outpatient management.

THREE QUESTIONS

When discussing the conversion from OBS to IPS, the reviewing clinician needs to address three questions. To support the conversion, at least one should be present.

Are there significant events since admission? Since the beginning of OBS, is there evidence of one or more of these three eventsthat support conversion to IPS
- An escalation of care, e.g., initiation of a heparin drip.
- New objective findings, e.g., worsening leukocytosis on the second day of hospitalization.
- Documented clinical concerns, e.g., “The patient remains weak, and at increased risk of falls. Therapy is ordered.”
What is the length of stay (LOS) since care was initiated? Has, or will, the length of stay (LOS) exceed (ed) two-midnights for traditional Medicare. Or, in the case of Medicare Advantage and commercial plans, does/will the LOS exceed a normal period of observation services. “Normal” being defined as < 48 to 72 hours.
Is there clinical instability that prevents discharge? This instability relates to discharge to their pre-hospitallevel of care. The resources available to the patient in the post-hospital setting are factors that need to be included in determining the MN of hospitalization. This again relates to the predictable risk of adverse events. Consider, for example, the 84-year-old with acute urinary tract infection and acute encephalopathy, improving by day 3, but who continues to require physical therapy and nursing care. If the pre-hospital setting was a SNF, she might be stable to return to the SNF. If she was residing alone in her home, with no local support, she likely is not yet stable to return home.

THREE “DON’TS”

When considering the MN of converting from OBS to IPS, or when developing the appeal.

Don’t allow the payor to deny the hospitalization based on a snapshot of the initial presentation. Payors are notorious for considering just the first portion of the patient encounter and relying on incomplete medical records when making their determination. For the inpatient converting from OBS to IPS, the MN is often evident only after considering the entirety of the medical record and the full hospital course.
Don’t apply admission Medical Necessity criteria for hospitalization when the patient is already hospitalized.
- Observation services are only provided in the hospital. This “status” is referred to “Hospitalization with observation services.” Once there is MN for hospitalization (inpatient or observation), any re-evaluation of the medical necessity can be viewed as a continued stay.
- After the first 24-48 hour (and before the second midnight for traditional Medicare), there are three sub-sets of OBS patients:
  - Continued hospitalization is no longer necessary à Discharge
  - New information is available that supports MN for IPS à Convert to IPS.
  - There is continued clinical instability for discharge à Convert to IPS.
- Don’t confuse “unsafe,” and “unstable.”
  - Payors will argue that it is not their problem that a discharge is considered unsafe by the hospital. An example is my patient on dialysis with wound-care issues, who by choice, lives under a highway in Michigan in the winter-time, and is otherwise ready for discharge. We can agree that this is a bad situation. But, by itself, it does not require hospitalization. Try to avoid developing arguments based on the concept of an unsafe discharge.
  - In contrast, patients that are unstable require continued medical care in the hospitalized setting. This instability may be obvious, such as the patient in cardiogenic shock on a balloon pump. At other times, it is less evident, and takes the form of a predictable risk to the patient.

It is important to lead in action. Check your own practices, start using unstable, rather than unsafe, and documentation regarding the patient’s predictable risk. For those working in concurrent reviews, consider an audit of your OBS patient population to determine what percentage would be appropriate for conversion to IPS. Work to incorporate the concepts that we have discussed today to support appropriate inpatient stays and potentially decrease downstream denials. Provide education to clinicians on the importance of documenting the risks of outpatient management. For those involved with appeals of payor denials, review your standard process, and validate that your appeals include these concepts.

[1] SHORT STAY. There is a wide variation of how payors and hospitals define a “short stay.” Some payors seem to consider a short stay to be anything less than 3 days and start denying “excessive” days once the patient is hospitalized more than 4 days. We believe the standard should be a stay of less than two midnights for Traditional Medicare and less than 48 hours for Medicare Advantage or commercial payors. Hospitals should routinely review all hospitalizations that are less than two midnights to ensure there is medical necessity for the inpatient status.

About the author

James Haering, DO, SFHM,CHCQM, serves as a Senior Physician Advisor, and consultant with JBH Solutions.

A practicing hospitalist with 30+ years of clinical practice, at all levels of patient care, including outpatient clinics, Acute Care Hospitals, Skilled Nursing Facilities, and Psychiatric hospitals.

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AHDAM

Denial Prevention. Appeal Success.

DISCLAIMER

December 2020

Good-bye 2020

As we say good-bye to 2020, let’s hope the year is remembered as one where our healthcare providers were faced with a monumental challenge that they rose to with a combination of grace, strength, pure grit, and compassion. Our hope is that 2021 will be a year of rest, recovery, peace, and a return to some sense of normalcy for our heroes in healthcare.

Upcoming (Free!) AHDAM Webinar with CEUs for AHDAM Members

Join us Wednesday, January 27, at 2:00 p.m. Eastern Time for AHDAM’s free webinar, COVID-19 Denials and Appeals. Denise Wilson, President of AHDAM and Senior Vice President at AppealMasters will be presenting on managing denials for COVID-19 care in the inpatient and outpatient settings. Denise will cover coding, clinical validation and medical necessity denial issues and appeal strategies. Although anyone can attend this 60-minute webinar, AHDAM is offering free CEUs to AHDAM members only. You can find out more on the website homepage www.ahdam.org. You can register here: COVID-19 Webinar

A Multidisciplinary Approach to National Coverage Determination (NCD) Denials

By Jillian Bisbe MSN, RN, CCDS, CDIP, CCS

Vice President, Denial Research Group + AppealMasters

National Coverage Determination’s (NCD) are nationwide medical guidelines that help determine whether Medicare will pay for an item or service. It’s common for hospitals that work these denials to deploy Utilization Management to appeal for medical necessity. While these cases often have a medical necessity facet, an important and often overlooked consideration are the diagnosis requirements set forth by the NCD. These are identified through the patient’s coded claim (UB04) and should be reviewed by a coder or clinician with a coding background.

Consider the following examples:

Transcatheter Mitral Valve Repair denial based on NCD 20.33

A claim was identified as a medical necessity denial. Upon review of the NCD, the denial was discovered to be due to principal diagnosis code I08.1, rheumatic disorders of both mitral and tricuspid valves.

Per NCD 20.33, either diagnosis code I34.0, nonrheumatic mitral (valve) insufficiency or I34.1, nonrheumatic mitral (valve) prolapse must be sequenced as the principal diagnosis to meet the requirement.*

The patient had both mitral and tricuspid valve regurgitation which, per coding guidelines, defaults to a combination rheumatic heart disease code, I08.1. Therefore, due to coding guidelines compliance, neither diagnosis code I34.0 or I34.1 would have been appropriate to code to meet the NCD.

The claim was appealed by a coder explaining the coding guidelines, correct code assignment based on the provider documentation and was successfully overturned.

Implanted Automatic Defibrillator denial based on NCD 20.4

A claim was identified as a medical necessity denial, however again, was noted to be denied due to the codes on the claim. Per NCD requirements, an ICD is reasonable and necessary for patients who have severe, non-ischemic, dilated cardiomyopathy.*

Upon review of the UB04 and the patient’s chart, it was noted that I42.9, cardiomyopathy, unspecified was coded as the principal diagnosis. This was coded in error as there was clear documentation by the provider that the patient had non-ischemic cardiomyopathy. The claim was rebilled with the more specific, appropriate diagnosis code, I25.5, ischemic cardiomyopathy, which corrected the claim to meet the NCD requirements and negated the need for an appeal.

Strengthen your Appeal

Consider a multidisciplinary approach the next time an NCD denial comes across your desk. A coding review will offer instrumental insight into your denial and potential appeal.

*Not all inclusive of NCD requirements

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Denial Prevention. Appeal Success.

DISCLAIMER

November 2020

Upcoming (Free!) AHDAM Webinar with CEUs for AHDAM Members

Join us Wednesday, December 2, at 2:00 p.m. Eastern Time for AHDAM’s free webinar, Successfully Master Level of Care Denials in a Managed Care World. Denise Wilson, President of AHDAM and Senior Vice President at AppealMasters will be presenting on avoiding denials and managing appeals with managed care payers for level of care decisions. Although anyone can attend this 60-minute webinar, AHDAM is offering free CEUs to AHDAM members only. You can find out more and register on the website homepage www.ahdam.org.

This program has been approved for one (1) continuing education unit toward fulfilling the requirements of the Certified Clinical Documentation Specialist (CCDS) certification, offered as a service of the Association of Clinical Documentation Improvement Specialists (ACDIS).

This program has been approved by AHIMA for 1.00 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA).

This program has been approved by the National Association of Healthcare Revenue Integrity (NAHRI) for one (1) continuing education units towards fulfilling the requirements of the Certification in Healthcare Revenue Integrity (CHRI).

This program has been approved by The Commission for Case Manager Certification for approval to provide board-certified case managers with 1 contact hour(s).

This activity has been submitted to the Northeast Multistate Division for approval to award contact hours. The Northeast Multistate Division is accredited as an approver of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

AHDAM White Paper Now Available

We are excited to announce a White Paper authored by Advisory Board Member Reginald (Reggie) Allen, MBA, RN, published on the AHDAM website. Reggie’s White Paper on Engaging Patients in Denials and Appeals gives great insight into how we as healthcare providers can partner with our patients to appeal inappropriately denied claims. The White Paper can be downloaded from the members-only Resources area of the AHDAM website at www.ahdam.org.

The CMS post-audit payer-adjusted DRG isn’t correct, but the initially billed DRG isn’t correct either.
Now, what do you do?

By Denise Wilson

It happens. The Medicare Administrative Contractor (MAC) reviews a claim for correct coding or clinical validation of the billed diagnoses. The MAC issues a decision on the audited claim, typically for a lower-weighted DRG based on removing or adjusting specific codes. The appeal specialist for the provider reviews the MAC’s recommended DRG and compares it to the billed claim and the medical record documentation. The specialist determines the MAC’s recommended DRG isn’t correct, but the originally billed DRG isn’t correct either. What comes next?

There’s a common understanding in the appeals world that once a claim has been audited by the payer, the provider’s disagreement with the audit results is resolved through the appeals process. But this scenario is a little different. For traditional Medicare claims, when the hospital or the MAC discovers an error on a bill, CMS allows the hospital to submit an adjustment request. Refer to the CMS Claims Processing Manual, Chapter 3 – Inpatient Hospital Billing 50.1 – Tolerance Guidelines for Submitting Adjustment Requests:

“When a bill is submitted and the hospital or the A/B MAC (A) discovers an error, the hospital submits an adjustment request using the ASC X12 837 institutional claim format or the Form CMS-1450, if the error is a change in the: • Diagnosis or Procedures that impact the assigned DRG code”

When the hospital disagrees with the MAC’s recommended DRG and determines that the originally billed DRG is incorrect, the hospital submits an adjustment request to correct the claim resulting in a new DRG. The new DRG on the corrected claim might be a higher-weighted or lower-weighted DRG than what was originally billed or what the MAC has recommended. It doesn’t matter. The goal is to submit a claim that is complete and accurate without consideration of the resulting DRG.

If a provider attempts to correct the claim through the appeals process, arguing for a new DRG, the MAC, the Qualified Independent Contractor, or the Administrative Law Judge will likely dismiss the appeal based on the guidance in the CMS Claims Processing Manual. In other words, at the time the MAC reviewed and issued a revised code set/DRG for the claim, the provider should have checked the claim. If the provider discovered an additional error, such as a missing code that impacted the assigned DRG, the provider should have submitted an adjustment request to include the missing code.

You can submit an appeal to argue against the changes suggested by the MAC review. But, if you want to adjust any additional coding that impacts the assigned DRG when you receive the MAC review decision, you must do so by submitting an adjustment and not requesting it through the appeal process.

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October 2020

Upcoming (Free!) AHDAM Webinar with CEUs for AHDAM Members

Application has been made to AHIMA for 1.00 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA).

Application has been made to the National Association of Healthcare Revenue Integrity (NAHRI) for one (1) continuing education units towards fulfilling the requirements of the Certification in Healthcare Revenue Integrity (CHRI).

This program has been submitted to The Commission for Case Manager Certification for approval to provide board-certified case managers with 1 contact hour(s).

Another Educational Opportunity!

AHDAM has embarked on a new affiliation agreement with the South Carolina Health Information Management Association (SCHIMA). AHDAM has agreed to provide a series of educational topics aimed at intermediate and advanced coders and billers in inpatient settings beginning in October and ending in March of 2021. AHDAM leadership will present each session and all sessions will be AHIMA approved. Session 1, Successfully Appealing Clinical Validation and Coding in Malnutrition, is also approved for 1 CEU by NAHRI and ACDIS. There are also 3 additional CEUs available for pre-recorded sessions being provided by Verisma Systems, Inc..

Pricing for the SCHIMA 2020 Virtual Fall Session event is being offered at the SCHIMA membership price of $35. The 90-minute live AHDAM educational webinar will be presented on Thursday, October 8, 2020 at 11:30 AM Eastern Time. You can learn more about this event and register for the webinar at https://www.elearningconnex.com/courses/schima-schima-2020-virtual-fall-session/.

Sepsis, COVID-19, and Higher-Weighted DRGs

By Denise Wilson

An interesting phenomenon is occurring. We all know that payers have been aggressively going after clinical validation of diagnoses in their audits, and sepsis is a diagnosis that payers very frequently challenge. Now with the coronavirus pandemic, we are seeing many inpatient encounters for COVID-19 where the patient also exhibits clinical indicators for sepsis. So, it’s not unusual to see inpatient claims include both a sepsis and a COVID-19 diagnosis.

Here’s an example of the coding for an actual case of a 40-year old male with no history of underlying disease suffering with fever, cough, and shortness of breath for 3 days. He was found to be hypoxic on examination and had patchy infiltrates on his chest x-ray. He was admitted as an inpatient. Shortly after admission he had a positive test for COVID-19. He was diagnosed with viral pneumonia and sepsis. His claim was coded as such:

Diagnosis Code	Description	POA
A41.89	Other specified sepsis	Y
U07.1	COVID-19, virus identified	Y
J96.01	Acute respiratory failure with hypoxia	Y
J12.89	Other viral pneumonia	Y

The coding resulted in the assignment of MS-DRG 871, Septicemia or severe sepsis w/o MV > 96 hours w MCC to the claim.

The commercial payer audited the claim and removed the sepsis diagnosis code claiming the code was not supported clinically. This is a pretty common denial issued by many payers, especially in light of the ongoing mismatch between clinicians and payers of what constitutes a diagnosis of sepsis. What is a little unusual in this case is that the removal of the sepsis code results in the assignment of the higher-weighted MS-DRG 177, Respiratory infections and inflammations w MCC. It’s not very often that the removal of a code by an auditor results in a higher weighted DRG.

Here’s what the payer suggested as appropriate coding for this claim:

Diagnosis Code	Description	POA
U07.1	COVID-19, virus identified	Y
J96.01	Acute respiratory failure with hypoxia	Y
J12.89	Other viral pneumonia	Y

The payer’s suggested coding resulted in the assignment of MS-DRG 177, Respiratory infections, and inflammations w MCC to the claim.

MS-DRG 871 carries a weight of 2.2396, while MS-DRG 177 carries a slightly higher weight of 2.2694. There’s not a lot of difference there. For this claim, the difference was only a few hundred dollars. Still, it’s additional money that would be available if the provider opts to just accept the payer’s revised claim. But, should the provider just accept the payer revised claim?

It might be tempting, but, in this case, the provider is appealing the payer’s decision, and rightfully so, in my opinion.

The ultimate goal of good coding practice is to present a claim that accurately captures and records all pertinent diagnoses that impacted the patient’s hospital stay. Anything less can result in grave consequences in a number of areas. Coding errors can impact the quality of patient care. Incorrect or incomplete coding of the medical record can result in inadequate or inappropriate treatment. On a financial level, coding errors can lead to delays in reimbursement or inappropriate reimbursement including being paid more than what is rightfully owed. Patterns of inappropriate coding can also lead to claims of fraud or abuse of the system.

In this case, there was good documentation in the medical record to clinically support the sepsis diagnosis. So, it’s appropriate for the provider to disagree with the payer’s decision to remove the sepsis diagnosis. The provider’s disagreement is voiced in the form of an appeal, asking for the sepsis diagnosis to be returned to the claim, even when that action results in a lost opportunity to gain a higher payment on the claim.

September 2020

Upcoming (Free!) AHDAM Webinar with CEUs for AHDAM Members

Join us Wednesday, October 7, at 2:00 p.m. Eastern Time for AHDAM’s free webinar, Identifying Payer Denials and Creating Successful Clinical Validation Appeal Strategies. Karla Hiravi, clinical appeal consultant at AppealMasters will be presenting on how to distinguish clinical validation denials from coding denials and how to apply successful clinical validation appeal strategies. Although anyone can attend this 60-minute webinar, AHDAM is offering free CEUs to AHDAM members only. You can find out more and register on the website www.ahdam.org.

This program has been approved for one (1) continuing education units towards fulfilling the requirements of the Certification in Healthcare Revenue Integrity (CHRI), offered as a service of the National Association of Healthcare Revenue Integrity (NAHRI).

Application has been made to AHIMA for 1.00 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA).

This program has been submitted to The Commission for Case Manager Certification for approval to provide board-certified case managers with 1 contact hour(s).

Another Educational Opportunity!

Appealing Medicare Advantage Denials as a Non-Contracted Provider

By Denise Wilson

There was an interesting discussion just recently on the RAC Relief Google Group regarding appealing denials from Medicare Advantage organizations (MAOs) when an entity is a non-contracted provider (NCP). If you aren’t a member of the RAC Relief Google Group, you should be. Send an email to Dr. Larry Hegland at [email protected] and ask to join.

A member of the group reported that The Centers for Medicare and Medicaid Services (CMS), in response to inquiries from providers, has recently issued a memorandum to MAOs reminding them that an NCP who has furnished a service to an enrollee can be a party to an organization determination and, as such, the NCP has the right to request an appeal.

The Code of Federal Regulations (C.F.R.) at 42 C.F.R. § 422.566(b)(3) clarifies that an ‘organization determination’ includes an MAO’s “refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by the MA organization”. The regulations go on to state that an NCP who has furnished services can be a party to the organization determination as an assignee of the enrollee and request an appeal in accordance with 42 C.F.R. § 422.574(b) and 42 C.F.R. § 422.578.

The regulations at 42 C.F.R. § 422.574(b) define an assignee of the enrollee as “a physician or other provider who has furnished a service to the enrollee and formally agrees to waive any right to payment from the enrollee for that service”. The formal agreement is made by completion of a waiver of liability form or similar signed statement from the provider. In short, as long as the waiver of liability is in place, the NCP is afforded full administrative appeal rights. CMS provides a waiver of liability form at https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Model-Waiver-of-Liability_Feb2019v508.zip.

To put this in simpler terms, if the MAO pays a claim as submitted, but then reopens the claim and reverses the original payment, that constitutes an organization determination that is appealable by the NCP, as long as the NCP completes a waiver of liability for that claim. The denial does not have to be a full denial or a zero payment in order for the NCP to be afforded appeal rights. As stated above, 42 C.F.R. § 422.566(b)(3) states a “refusal to provide or pay for services, in whole or in part”. So, downcoding of DRG codes or determining a patient should have received outpatient instead of inpatient services would qualify as organization determinations that are appealable by the NCP.

If you’re experiencing MAOs not following published procedure, you can file a complaint to your CMS regional office. In the meantime, you can push back through the appeals process by citing the relevant regulations posted at 42 C.F.R. Part 422 Subpart M in your appeals.

Additional Resources:

CMS provides a Part C Appeal Mailbox at https://appeal.lmi.org/DAPMailbox where providers can submit questions regarding this topic. The mailbox site also houses additional CMS guidance on the Part C appeals process.

Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (PDF)

https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf

Chapter 13 – Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health Plans) (PDF)

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c13.pdf

Title 42 Part 422 Subpart M

https://ecfr.io/Title-42/Part-422/Subpart-M

August 2020

Membership Update

AHDAM has passed the 200 mark for memberships! How exciting to have so many members of the denial and appeal industry interested in being a part of this growing community! Now that we have our free webinars (with free CEUs for AHDAM members) up and running, we will begin focusing on building a structured education program that will lead to certification. We plan to have certification up and running within a year. So stay tuned!

Upcoming (Free!) AHDAM Webinar with CEUs for AHDAM Members

Join us Wednesday, August 26 at 2:00 p.m. Eastern Time for AHDAM’s free webinar, Identifying Payer Denials and Creating Successful Coding Appeal Strategies. Malissa Powers, B.S., RHIT, CCS, CDIP CICA, appeal consultant at AppealMasters will be presenting on how to distinguish clinical validation denials from coding denials and how to apply successful coding appeal strategies when the denial rationale is not clear. Although anyone can attend this 60-minute webinar, AHDAM is offering free CEUs to AHDAM members only. You can find out more and register on the website www.ahdam.org.

This program has been approved for 1.00 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.

This program has been pre-approved by the Commission for Case Manager Certification to provide continuing education credit to Certified Case Managers (CCMs).

This activity has been submitted to the Northeast Multistate Division for approval to award contact hours. The Northeast Multistate Division is accredited as an approved of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

Prior Authorization for Certain Hospital Outpatient Department (OPD) Services

By Denise Wilson, MS, RN, RRT

CMS began a prior authorization requirement on July 1, 2020, for certain outpatient hospital department services. The services selected for the prior authorization requirement are those that CMS feels are those that likely represent cosmetic surgical procedures that are not covered by Medicare. You can access the list of services at https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf. In their open door forum, CMS made it clear that they expect the outpatient hospital department, not the provider performing the service, to initiate and obtain the prior authorization.

Most A/B (Part A and Part B) Medicare Administrative Contractors (MAC) will have guidelines or even a prior authorization form available on their website to help the provider obtain preauthorization for services. You can find your A/B MAC here: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs. I’m all for using checklists to help get it right the first time, but I would recommend going a step further. Ensure that your checklist is detailed enough for anyone doing preauthorization work to know exactly what is required to pass muster.

For example, let’s look at National Government Services (NGS), the A/B MAC for the J6 jurisdiction which includes Minnesota, Wisconsin, and Illinois. Their website (see link below) provides a checklist for blepharoplasty, eyelid surgery, brow lift, and related services. The checklist follows NGS’s published local coverage medical policy article (A52837). Medical policy articles address local coverage, coding, or medical review related billing and claims considerations, and may include coding instructions. Most MACs will have published either a Local Coverage Determination (LCD) or a medical policy article, or both, that describe the clinical criteria and documentation requirements necessary for appropriate payment for the services CMS has identified for preauthorization. Comparing the checklist NGS provided for blepharoplasty services to their medical policy article reveals more specificity in the medical policy article.

Here’s an example. The checklist states, “Documented subjective patient complaints which justify functional surgery (vision, ptosis, etc.).” However, the medical policy article requires documentation of commonly found signs and symptoms such as (but not limited to):

“Significant interference with vision or superior or lateral visual field, (e.g., difficulty seeing objects approaching from the periphery);
Difficulty reading due to superior visual field loss; or,
Looking through the eyelashes or seeing the upper eyelid skin.”

The article provides a more detailed description of the required documentation than the simple sentence provided by NGS on its website checklist.

Consider making your internal checklist for prior authorization specific to the requirements defined in the LCD or article. Under “Documented Patient Complaints,” list the three complaints provided by NGS, including space to list signs or symptoms other than those identified by NGS. A list of well-defined signs or symptoms makes it easier to verify the documentation submitted by the provider or to query the provider for more specific documentation before requesting preauthorization.

Other Things to Remember about Prior Authorization

CMS’ has the authority to exempt a provider from the prior authorization process based upon a provider’s demonstrated compliance with Medicare coverage, coding, and payment requirements in 42 CFR §419.83(c). Providers that achieve a prior authorization provisional affirmation threshold of at least 90 percent during a semiannual assessment (84 FR 61448) should be exempted. Exemptions for providers who qualify will begin being granted sometime in Calendar Year 2021.

Generally, the claims that have a provisional affirmation decision will not be subject to additional review; however, CMS contractors, including Unified Program Integrity Contractors or MACs, may conduct targeted pre- and postpayment reviews if the provider shows evidence of potential fraud or gaming. In addition, the Comprehensive Error Rate Testing contractor must review a random sample of claims for postpayment review for purposes of estimating the Medicare improper payment rate.

For More Information:

List of services requiring preauthorization:

https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf

Find your A/B MAC:
https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs

National Government Services:

https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/complianceandaudits/medical-review/medical-review-focus-areas/medical-review-focus-areas-detail

Final rule:

https://www.govinfo.gov/content/pkg/FR-2019-11-12/pdf/2019-24138.pdf

Prior authorization webpage:

https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services

July 2020

Membership Update

The limited time discount on membership has been extended to July 31, 2020. If you have found value in your AHDAM membership please invite your colleagues to join before the price goes up. Membership will increase to $125 per year beginning August 1, 2020.

First (Free!) AHDAM Webinar

Join us Wednesday, July 22 at 11:00 a.m. Eastern Time for AHDAM’s first free webinar. David Glaser and Denise Wilson will be presenting on The Legal and Regulatory Aspects of Appeals in Denial and Appeal Management. This 60-minute webinar is offering free CEUs. You can find out more and register on the website www.ahdam.org.

How To Counter Denial Rationale

By Karla Hiravi, BSN

Auditors get savvier all the time. Unfortunately, the auditors’ rationale used to deny diagnoses on a clinical basis is frequently incomplete, inaccurate, or based on what appears to be a quick review of the medical record. I like to think the appeal writer’s Golden Rule is, “Never, EVER assume the auditor is correct in their rationale to deny a diagnosis.” Read the denial reasons with a critical eye, and start to think immediately about how you might counter any inaccurate claims.

Don’t forget to look at the sources used for the denial. CV denials should be based on clinical medical literature. Let’s look at some specific examples of misleading or inaccurate denial reasons, plus some ways to invalidate them in appeals. Use the reviewer’s language when you can.

Acute Blood Loss Anemia:

Reviewer: “Acute blood loss anemia is denied because there was only a slight drop in the H&H from 11.2/33 to 10/30.”

Hospital rebuttal: The reviewer failed to consider the preoperative H&H found in the anesthesiology consultation (p. 28) in the medical record. The preoperative H&H was 15/45. The H&H values stated by the auditor were postoperative only. The patient’s hemoglobin level dropped 5 grams, and the hematocrit level dropped 15% compared to the preoperative H&H.

Reviewer: “Acute blood loss anemia is denied because there was only an EBL of 100cc.” Source documents from the payer included a reference for postpartum hemorrhage.

Hospital Rebuttal: The reviewer failed to consider that while there was an EBL of 100cc, there was also grossly bloody hemovac drainage totaling >500cc in 24 hours. Supporting documentation is found in the I and O flowsheet for 1/1/20 (p. 163), the nurse’s note from 1600 1/1/20 (p. 238), and the physician’s progress note from 0715 on 1/2/20 (p. 75).

Also, it is concerning that one of the references used to deny the diagnosis of acute blood loss anemia came from an article about postpartum hemorrhage. The patient, in this case, was a 58-year-old man.

Pancytopenia:

Reviewer: “Per the guidelines referenced below, pancytopenia is a clinically significant and abnormally low level of all blood cells produced by the bone marrow. Pancytopenia includes a clinically significant low level of red blood cells (RBCs), white blood cells (WBCs), and platelets. Though the WBCs and platelets were significantly low, the hemoglobin and hematocrit levels did not meet the clinical criteria for this diagnosis. Pancytopenia continues to be denied.

References: Coding Clinic, Fourth Quarter 2011 Pages: 91-92, Drug-induced pancytopenia; Coding Clinic, First Quarter 1991, Page 14, Pancytopenia with other diseases.”

Hospital Rebuttal: It is concerning that the auditor appears to be confusing hemoglobin and hematocrit levels with an RBC count. They are different. Pancytopenia is defined, as the auditor stated initially, by a decrease in the three blood cell lines: RBCs, platelets, and WBCs.

This patient had a decrease in all three cell lines, as evidenced by WBC 2.12 (L) [4.0 – 10.0 x 100/u/L), RBC 3.78 (L) [4.00 – 5.20 x 100u/L], and platelets of 93 (L) [140 – 400 x 1000 u/L] on 6/7/18 and found on page 72 of the medical record.

It is equally concerning that the auditor used Coding Clinics to deny a diagnosis on a clinical basis, which is a direct violation of the intended use of Coding Clinics.

Coding Clinic, Fourth Quarter 2015: Page 20 states, “…Coding Clinic may still be useful to understand clinical clues…Users may continue to use that information, as clues – not clinical criteria.”

Coding Clinic, Third Quarter 2008 Page: 16 states, “As stated in Coding Clinic, Second Quarter 1998, pages 4-5: Any clinical information published in Coding Clinic is provided as background material to aid the coder’s understanding of disease processes. The information is intended to provide the coder with ‘clues’ to identify possible gaps in documentation where additional physician query may be necessary…”

Newborn Respiratory Distress Syndrome:

Reviewer: “Respiratory distress syndrome in this newborn will be removed from the claim. While the patient suffered from respiratory distress, there is no clinical evidence that respiratory distress syndrome was present. The CXR showed hyperinflation of the lungs rather than hypoinflation. TTN was documented repeatedly for the first two days as a potential diagnosis.”

Hospital Rebuttal:

The auditor claimed that the chest X-ray showed hyperinflation, rather than hypoinflation. The auditor did not relay that the baby was on a CPAP at the time of the chest X-ray. A CPAP can absolutely cause hyperinflation of the lungs. The radiologist even alluded to that with the statement, “Lungs appear mildly hyperinflated which may be secondary to CPAP administration” (CXR Report, p. 163).
The auditor claimed that TTN was documented repeatedly for the first two days as a potential diagnosis. Of concern is that the above statement does not state that RDS was also repeatedly documented as a potential diagnosis. For the first two days, documentation was “TTN vs. RDS.” After study, the baby was diagnosed with RDS, as clearly documented after day two.
Surfactant was considered for this baby if she did not improve (Progress Note, p. 56). Surfactant would never be considered for TTN.

Hyponatremia:

Reviewer: “In current practice, hyponatremia with a sodium level > or = 130 mEq/L, while slightly below the normal range for your laboratory, is clinically insignificant and does not typically require treatment.”

Hospital Rebuttal: We don’t disagree – most patients would not typically require treatment. However, this elderly lady did. She had acute appendicitis that was very close to rupturing and needed urgent surgery (H&P, p. 112). She needed to be medically optimized as best as could be done before the surgery. That included a 1000cc bolus of NSS after her BMP came back with a sodium level of 133 (L) [136-144 mmol/L] (ED Note, p. 17). Of note, Adrogue, H.J. & Madias, N. (2014) state that isotonic saline can be used in the treatment for hyponatremia. The reference can be seen below in the Evidence-Based Guidelines section of this appeal.

Normal Vital Signs:

Reviewer: “The patient’s vital signs were within normal limits.”

Hospital Rebuttal: The patient was bradycardic and hypothermic while in the ED (ED Note, p. 38). During the hospitalization, he declined rapidly and suffered from hypoxemia to the point he was obtunded (Rapid Response Note, p. 146).

Pneumonia:

Reviewer: “The patient’s chest x-ray reflected ‘Stable but abnormal lungs with interstitial lung disease and evidence of ossification within the areas of fibrosis unchanged since 2015. No edema or acute parenchymal process.'”

Hospital Rebuttal: The above statement is accurate. However, the auditor failed to mention that the physician discussed the CXR findings with the radiologist, who stated there might be a consolidation in the left lower lobe (Progress Note, p. 238). Also, chest x-rays are not 100% diagnostic 100% of the time. That is why the radiologist suggested a CT scan for further investigation if the physician felt it was needed (CXR Report, p. 302).

Reviewer: “A CT of the chest did not show evidence of pneumonia. Pneumonia will be removed from the claim.”

Hospital Rebuttal: Multiple chest x-rays and an ultrasound revealed evidence of pneumonia. A CT did not – but that exam was very limited by movement, a large pleural effusion, and a lack of contrast (CT Chest, p. 67). The examining and treating physicians evaluated the patient, lab findings, radiologic findings, and determined that he did, indeed, suffer from pneumonia.

Aspiration Pneumonitis:

Reviewer: “The physician noted that the suspicion for a true healthcare-associated pneumonia or aspiration pneumonia was quite low.”

Hospital Rebuttal: The above is accurate as far as it goes; however, the statement goes on to say, “… and he likely had aspiration pneumonitis, without a true infection.” That the entire statement was not included is quite disturbing as, without it, the true meaning is easily misinterpreted.

Sepsis:

Reviewer: “Sepsis is denied because the patient did not meet SOFA criteria.”

Hospital Rebuttal: This patient required care in the ED and a non-ICU floor. Singer et al. (2016) state that qSOFA criteria are applicable in non-ICU wards such as the ED. The full reference can be found below in the Evidenced Based Guideline section. This patient fully met qSOFA criteria with an altered mental status, a respiration rate of 22, and SBP <90. The physician documented that qSOFA criteria were used to establish the diagnosis (H&P, p. 50).

Regardless of the criteria used, there is no consensus in the medical community as to what constitutes “Sepsis.” The patient even met the SIRS definition due to infection (leukocytosis + respiratory rate of 22). This patient was septic by multiple definitions.

Summary

In summary, scrutinize the rationale for the denial, including sources used by the auditor. Don’t be afraid to use the auditor’s own words to refute any “alternative facts.” Back up your point of view with the medical record and medical literature. And don’t forget the “Golden Rule” of appeal writing: never, EVER assume the auditor is correct.

June 2020

Appeal Writing Workshop

New articles have been posted for coding and clinical validation appeal writing. The coding education includes Preparing for the Appeal, and Understanding the UB-04. The clinical validation appeal writing articles will help you understand when a denial is a clinical validation denial, and how to provide a roadmap in the appeal. A roadmap provides the payer auditor an easy way to find the significant documentation in the medical record that supports the claim as billed. The easier it is for the payer to find the documentation, the easier it is for the payer to overturn the denial.

Productivity

The question of productivity of appeal writing comes up often during appeal writing education. How long should it take someone to write an appeal? No standard exists, and defining a standard may be quite difficult. The difficulty in establishing a standard is due to the variety of denial issues, appeal writing methodology, and experience of the writer.

Denial Issues

Healthcare denial and appeal management departments should define the types of denials received for reporting and analysis purposes. Each denial received should be categorized under a denial issue or denial type. The denial issue is the reason the payer gave for the denial. A denial issue of “Level of Care” means the payer declined to pay for the inpatient admission. A denial issue of “Medical Necessity” means the procedure or service provided was not medically necessary per the payer’s assessment. Often a medical necessity denial is based on utilization criteria defined in Medicare’s National or Local Coverage Determinations, or a commercial payer’s Clinical Policy Bulletin. Coding can be a primary denial issue, but for additional detail, recognize subtypes such as Coding – Principal Diagnosis, or Coding – Procedure. Other denial issues might be Clinical Validation or Technical/Administrative denials. Categorizing denials into a denial issue is the first step to developing a standard for appeal writing productivity.

Appeal Writing Methodology

There are varying appeal writing methodologies that providers may consider adopting. Methods can vary based on the denial issue, the payer, or the anticipated final decision-maker. In general, though, the denial issue has the most significant impact on writing the appeal. For example, an appeal for the medical necessity of an outpatient procedure may involve the submission of physician office notes required by the payer to support the claim as billed. In this case, the appeal takes very little time to write and submit, that is, if the physician’s office notes are readily available and easy to obtain. An appeal for the level of care involves assembling a variety of information from the medical record into a persuasive argument. Many people believe a sizable medical record or a long length of stay contributes to the time to write an appeal. In reality, a medical record with excellent supporting documentation can significantly decrease appeal writing time regardless of the length of stay.

Medicare or Medicaid appeals may eventually pass through a hearing stage before an administrative law judge. In those instances, it may be beneficial to start the appeal process with a well-crafted appeal letter that includes legal or regulatory arguments and is written in a more formal language as expected in a legal document. That way, the letter serves all levels of appeal without requiring additional editing, unless, of course, the denial issue changes during the life of the appeal. Appeals submitted to non-clinical decision-makers such as administrative law judges may require more in-depth clinical or coding explanations than appeals filed with a commercial payer’s medical director.

Determining Productivity

Determining a productivity standard for appeal writers is easier if the writers adhere to the same methodology. Do a time study over a few weeks where the writers record their time writing the appeal. Assess the average appeal writing time by denial issue. For coding and clinical validation denials, it may be worthwhile to log the number of codes that are being challenged by the payer. Arguing support for 2 to 5 denied diagnoses codes will take longer than arguing for the support of 1 code. Consider recording just the appeal writing time. Separate the time required to gather documents or otherwise prep for the appeal. Administrative support staff should prep and submit appeals. Review your findings and determine whether appeal writing time seems appropriate or excessive, especially in the context of success rates. Appeal writing times that seem excessive are an invitation to break down the process and identify opportunities for improving efficiencies. And, stay tuned to AHDAM as we prepare for a members survey that will help shed light on productivity standards for appeal writers.

May 2020

Membership Update

Congratulations on becoming a charter member of AHDAM! Since opening its doors in April, there has been a lot of excitement about this new association. In the first month we have over 100 members representing 25 states in the U.S. Our membership is represented by nurses, physicians, coders, CDS, analysts, auditors, and billers, among others. If you find value in your membership, please invite your friends and colleagues to join.

More importantly, we invite you to be an active member of the association. You can submit your denial and appeal management questions in the Ask the Expert area of the website. We also invite you to submit sample job descriptions and policies and procedures to share with the community. Submit what you would like to share to Denise Wilson at [email protected].

Appeal Writing Workshop

We hope you have visited the Appeal Writing Workshop and found the information posted there helpful. Over time, we will post additional articles to fill out the entire workshop. The most recent article, Speaking the Payer’s Language, discusses an essential aspect of successful appeals. There are many ways the appeal writer can incorporate the payer’s language into the appeal. To speak the payer’s language, you must first understand the clinical, regulatory, and contract language the payer used to decide to deny or short pay the claim.

The payer’s language impacts many aspects of the denial. The use of clinical language comes to mind when appealing the medical necessity of a procedure or service and in clinical validation appeals. Coding standards are essential in coding appeals. A knowledgeable appeal writer understands that appeal arguments frequently include arguments beyond clinical guidelines or coding standards. The use of regulatory and contract language ensures payers are operating appropriately under administrative and legal constraints. Did the payer employ auditors with the appropriate skillset to review and deny the service in question? Did the payer follow the audit process as outlined in the payer-provider contract? Did the payer return an appeal decision within the timeframe required by the state insurance board? The Appeal Writing Workshop will cover all of these critical aspects of successful appeals with future articles, so stay tuned.

The Appeal Writing Workshop also includes some sample appeals. Denial Research Group + AppealMasters provided the appeals and templates in the workshop. However, we invite all AHDAM members to submit successful appeals and appeal templates for publication and sharing among members. Submit your documents to Denise Wilson at [email protected]. Please ensure there is no protected health information or other identifying information in your submissions.

COVID-19 Resource Center

We are working daily to keep the COVID-19 Resource Center up to date with the latest information. AHDAM is keeping the information in the resource center focused on healthcare denial and appeal management. Besides reposting government guidelines on coding and billing, we are also tapping into industry experts to tell us what they anticipate will be future denial and appeal issues. Their timely advice will help you understand what to do now for denial prevention. You can access the COVID-19 Resource Center from our main page at www.ahdam.org. If you are already appealing COVID-19 denials, we want to hear your stories. Send your story for sharing to Denise Wilson at [email protected]. Please be sure there is no protected health information or other identifying information in your submission.

Stay safe. Be well.

April 2020

Welcome!

I am so happy that you have decided to join the nation’s only association dedicated to Healthcare Denial and Appeal Management (AHDAM). It has become evident over the years that managing healthcare denials has become an industry unto itself. This industry requires people with specialized skills and expertise to successfully navigate the complexities of healthcare insurance denials. Today’s denial and appeal management expert demonstrates success in overturning inappropriately denied claims while working to prevent denials from occurring. Success in denial and appeal management comes through education, collaboration, experience, and industry knowledge. AHDAM strives to support and advance healthcare denial and appeal management professionals by providing the tools necessary for success.

As a member of AHDAM you will receive exclusive access to white papers, sample policies and procedures, sample job descriptions, and the monthly newsletter, The Benefit. You’ll also have access to the members-only appeal-writing workshop, which provides self-paced study of appeal writing best practices with real-life examples.

I invite all members of AHDAM to work collaboratively to share knowledge and experiences. I want you to have a voice in developing this association to meet your needs. And, I am thrilled you are joining us on this journey to bring education, resources, and recognition to those working in the field of healthcare denial and appeal management.

If there’s anything I can do for you, please reach out to me personally at [email protected] or phone 410-321-4960

Denise Wilson

President