UNITED HEALTHCARE MINUTES March 11, 2013 RIC/RAC Meeting

Transcription

1 UNITED HEALTHCARE REPRESENTATIVES PRESENT: Ms. Linda Fetsch Ms. Rhona Waldrep Mr. Michael Jones FACILITATORS: Mr. Ingram Haley Ms. Karen Northcutt MR. HALEY: Now, let s welcome United HealthCare. 1. Follow up to question #1 and Additional/Open Discussion from the November 5, 2012 RIC/RAC meeting. If an inpatient claim is audited and denied can you rebill as outpatient/observation if you do not have an observation order? Hospitals certainly can re-bill as observation or outpatient and receive payment. To clarify, Observation does not require authorization. That said, services provided during an Inpatient admission that do not meet Inpatient criteria and are therefore denied can be re-billed as Observation and be eligible for payment. A corrected hospital bill type would be appropriate for this situation. MS. FETSCH: Hospitals can be rebilled as observation or outpatient and receive payment. So I'm not really clear what the confusion is. I'm not sure who posed that question. We can have a separate discussion about it. But yeah, you could rebill it as observation and get paid for it. None of that is going to matter because there's nothing to require any type of notification at all. So there shouldn't be any problem with getting it paid. And of course, if you did have a problem, I would need you to reach out to me directly. And like I said, if somebody wants to talk about this one afterwards and maybe give me a good example, I'll take a look at it. But there shouldn't be an issue. You should be able to rebill it and the claim should be paid. (Inaudible question) MS. FETSCH: If you're going to change anything on the bill, you should run it as a corrected bill. But I would change your bill type. Submit it as a corrected bill type. THE SPEAKER: If I could get just a little bit more clarification. Last meeting we were told the order just really didn't matter. It was based on medical necessity. But we had a chart pulled and it was denied clearly because of the order. And that's the only reason that they were denied. Because it was billed inpatient. Said, well, you don't have an inpatient order. But it was approved. We talked to whoever our representative was when call clinicals in. MS. FETSCH: Sure. Page 1 of 7

2 THE SPEAKER: But then it got denied because it was no order. So if we could just get something, even just in writing, that says the order doesn't matter. MS. FETSCH: Observation doesn t require an order, now, if it was inpatient initially and then changed to observation, was it that it didn't meet inpatient criteria? THE SPEAKER: The patient did meet inpatient criteria, but it said the order was missing. MS. FETSCH: The inpatient order was missing? THE SPEAKER: Yes. I mean, it was billed as inpatient and it was certified or precertified as inpatient while the patient was in the facility. But the order didn't make it to the chart and it was denied because of no inpatient order. MS. FETSCH: Instant notification. Okay. That makes a little bit more sense to me. So the inpatient order was gotten after the fact. In that type of case, you will get a denial. Now, you can rebill it as observation. I can't tell you not to bill it like that. And you probably will get paid. But I can't really tell you guys how to bill claims. THE SPEAKER: No. I was just trying to find out what is acceptable, then, I mean, is the order necessary or not, period. I mean, is it going to be based on the order? MS. FETSCH: An observation order is not needed. I'm going to say, no, that's not necessary. THE SPEAKER: So you can bill observation with inpatient orders? MS. FETSCH: Yes. THE SPEAKER: This was a commercial. And is this true for Advantage and commercial as far as billing observation regardless of the order that's on the chart? MS. FETSCH: You can bill observation regardless of the order on the chart. Yes. THE SPEAKER: But inpatients, you're saying, are going to require an order even if you're given an authorization? Because sometimes when the reviewer calls us back and says it meets inpatient or we're going to approve this number of days, the patient is discharged at that point. And we don't write on discharge records normally. So what process would you recommend or how do you expect us to get that order? MS. FETSCH: I would call back to the clinical folks. Each facility has an actual RN that's designated to them. I would call back your nurse and discuss that with them. Does that help? Does everybody know who their RN is for their facility? THE SPEAKER: You're saying call them back for authorization? MS. FETSCH: I would call them back if you're saying that you got an order and they were discharged ahead of time is what you're telling me, correct? Page 2 of 7

3 THE SPEAKER: Absolutely. MS. FETSCH: Yes. If you've got any question on that and that comes back to a clinical issue, that's who you should be reaching out to, would be the RN. THE SPEAKER: And they are approving it as inpatient based on the medical necessity, but there's no order. And that happens mostly with the weekend case, where the patient was in on the weekend. And on Monday or Tuesday, they're approving it as inpatient, but there's no way to get an inpatient order on that record at that point, unless there's something in your policy that says that we can write them retrospectively. Like with Medicaid, you can get an order up to 30 days and so forth. MS. FETSCH: Well, on weekend notifications, you guys have up till 5:00 on Monday. THE SPEAKER: To write the authorization number. We're getting you the clinicals. It's the order that is not there. MS. FETSCH: Order from the physician. I've got you. Okay. THE SPEAKER: Hey, Linda. The requirements for physician orders are Medicare requirements. So maybe we need clarification. Does the commercial side require an order? Because I don't believe those should be being denied for lack of orders. MS. FETSCH: I don't think so either. THE SPEAKER: Because only Medicare has all those rules about orders. Does that make sense? MS. FETSCH: Yeah. I mean, Medicare is going to be different because CMS regulates that. So yeah. I will check into that. THE SPEAKER: But she had a denial from the commercial. MS. FETSCH: Yeah. So I would like to see that, I mean, if you can get me that example. You can it to me. I'll give you my card. And if you can send that to me, I'll take a look at it and see what actually happened with it. THE SPEAKER: But are you saying the commercial and the Advantage are the same rules? MS. FETSCH: No, not necessarily. Advantage plans are going to follow Medicare. THE SPEAKER: Follow Medicare rules? MS. FETSCH: Yes. THE SPEAKER: Because if it's a Medicare, remember observation is not a patient status. MS. FETSCH: I'm going to check into physician orders on a commercial. If you can get me that example, I'll take a look at it. Page 3 of 7

4 2. We have been receiving denials on our Radiology professional claims for patients that were treated in the emergency room. The denial states that the service is included with another service. The UHC representative informed us that if someone other than the ER Doctor read the radiology test, we should re-submit the claims with a signed report from the radiologist for payment. We asked if they would be denied for timely filing and she told us no. We resubmitted several claims with the radiologist report attached and they were denied for timely filing. Is there a way for us to get these claims paid? This is a known limitation and does happen. If you have contacted United Customer Service or sent in a request for reconsideration and you have not gotten resolution then you should be reaching out to your Hospital Advocate and the issue can be escalated. MS. FETSCH: That's a known system limitation and that does actually happen from time to time. And those issues should be brought to my attention once you've tried reaching out to customer service and obtained a reference number. You can bring those to me and I'll escalate those through the market service agent, I'll pass those on and get those processed. 3. Consider a Medicare Advantage patient that elects hospice in the middle of the month and is admitted to the hospital after this within the same month and revokes hospice at admit. Who is responsible for payment of the hospital claim? Medicare? Or the HMO/Medicare Advantage? If it is outside of the hospice plan of care, should we send the claims to Medicare or the Medicare Advantage plan? Does the capitation payment affect who is responsible for the claim? Attachment They can review the UHC Medicare Advantage Plan Hospice Coverage Summary at the following link that is uhconline.com. US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20an d%20protocols/unitedhealthcare%20medicare%20coverage/hospice_uhcma_cs.pdf We do not pay or deny claims based on a cap payments for Hospice - it is per the Hospice dates. Provider should not worry about cap payments, they need to bill Traditional Medicare during the members Hospice time period as UHC will not pay since Medicare is always the payer on claims that are within the members Hospice period.. Page 4 of 7

5 Our system Hospice dates start on the date the member elects hospice and then are set to the end of the month when Hospice was termed since Hospice coverage through Medicare runs to the end of the month when hospice was termed. **Per CMS guidelines when a member elects Hospice status all claims during that time frame are to be submitted to Traditional Medicare for payment. Claims need to be billed to Medicare correctly with a 07 condition code for facility claims and a GW modifier for physician claims if the services are non-hospice related. MS. FETSCH: This is a long one. I suggest that you review the UHC Medicare Advantage Plan Hospice Coverage Summary, and I attached the link for you. We don't pay or deny claims based on cap payments for hospice. So I suggest you guys read that. And if you have additional questions, you can feel free to reach out to me. 4. Are these services covered for OP hospital technical component performed by a PHD Dr. of Clinical Psychology: Health & Behavior assessment Health & Behavior intervention; individual Health & Behavior intervention; group Psychological testing Should the NPI of the clinical psychologist performing the service or the referring physician be on the UB04? These services are covered but require prior authorization. The NPI of the rendering provider should be used in billing these services. MS. WALDREP: Concerning any of the behavioral health services that are provided by the facility, that is carved out of your commercial and/or Medicare agreement and would need to be steered to UBH, or Optum Behavioral Health now. I'm not sure what their billing guidelines are or what their policies and procedures are around this at all. And we do not have access into their systems or their contracts. So unfortunately, I don't have a really good answer for you on Question No. 4, and I hate to redirect you. But I have no insight on what their advice or what their option would be. MS. FETSCH: And I did check with a colleague of mine on that question, and they did say that the NPI of the rendering provider should be used in billing the services, but they do require prior authorization. So that's the feedback that I got. But like Rhona said, really that question should go to UBH since they hold the contract. And it's really not a part of your commercial or your Medicare agreement. I do take issues for UBH, but I send them off to somebody else to look at. So if you have a UBH issue that you're having a problem with, you can send it to me, but I'm going to send it to that area for them because they're Page 5 of 7

6 the experts of that. So you can always bring those to my attention. But any type of questions related to contract and coding, really those should be directed to UBH. 5. E&M services provided by nurse practitioners in a hospital OP clinic setting can hospitals bill the technical component on a UB04? If yes, should the NP NPI be reported as the attending or should the attending doctor NPI be reported? The hospital billing would be the hospital paid. The hospitals NPI would be in box 56. The Nurse Practitioner or whichever attending physician s NPI would need to be on the UB in the attending field (box 76). MS. FETSCH: This one is a little bit tricky. I'm not sure who had this question. Rhona and I were talking about this earlier. But the hospital billing would be the hospital that would get paid. I'm kind of confused on the question. The hospital's NPI would be in Box 56. But in all reality, I believe that if you're going to bill a nurse practitioner, it would have to be dropped to a 1500 to do that. THE SPEAKER: I had the question. And I want to know, to bill for the hospital I'm going to give you the hospital NPI. But as far as who is referring the patient or providing the service for the patient can I give the nurse practitioner NPI as far as who is the attending or the referring. It would be attending. MS. FETSCH: Attending. I believe so. And I'll take that one back. I was kind of confused on that question. If you could get me your card we can talk after the meeting and I can write down your number. I'll call you directly and we can talk about that. THE SPEAKER: Thank you. MS. FETSCH: You're welcome. MR. HALEY: That concludes our formal questions. Does anybody have any follow-up questions or comments? Additional MS. FETSCH: I wanted to share a couple of things. The new 2013 administrative guide is now available; just so you're aware of that. ICD 10, United will be ready. All of our partners and everybody is planning to be up and running and ready to go. We will be doing some testing if anybody would like to get in on that. You can reach out to me, and if it's a fit, we'll definitely work with you on that. Also, I wanted to mention they do have an actual pilot out for records being accepted electronically. I know that's a big pain point for facilities to have to send records. So we're looking at maybe third quarter, and I can keep you guys posted on progress with that. So hopefully, by the third quarter we'll be able to accept some medical records electronically. THE SPEAKER: Good. Page 6 of 7

7 MS. FETSCH: Yeah. I agree. THE SPEAKER: I don't know if everyone else has seen this, but you have got a contract with EquiClaim now. They've requested close to 200 charts since January from us for DRG validation. And that's a lot. And we've got to send them in paper. So as quickly as that can come out, please let us know. MS. FETSCH: Yeah. I'll keep you posted on that, Shannon. I can't wait either. I'm so excited. I'm ready. And you and I can talk about that at a later time. I haven't heard that. So that's interesting. Anybody else got any questions? MR. HALEY: Thank you. (No response) Page 7 of 7