3/19/2014 RAC TEAM UM TEAM FINANCE HIM

Transcription

1 Karen Stoll, BSN, RN, CPC-H, Manager-Payor Services/Recovery Audit, Wheaton Franciscan Healthcare & Catlin Scheppler, BSN, RN, Recovery Audit and Appeals Nurse Analyst, Recovery Audit and Appeals Department, Ministry Health Care 2 RAC DEPARTMENT Manager- RN 2 Nurse Reviewers - familiar with Medicare rules and Manuals - Appeal writing experience 2 business analysts - Familiar with finance - Familiar with insurance billing Ancillary departments HIM Coders UM Nurses Hospital billing 3 1

2 Manage all federal audits and appeals for: 14 Hospitals 7 acute care 7 critical access Home health/hospice/dme Manage all commercial (including Medicare/Medicaid Advantage) audits and appeals for: 4 acute care hospitals 4 Recovery Audit and Appeals Department (RAAD) Centralized audit response team serving Ministry and Affinity Health Care Team 4.25 Registered Nurses 4.5 Database Coordinators 1 Director of Clinical Resource Management 1 Medical Director Locations Marshfield, WI Appleton, WI 5 ADR (or any other documentation request) received in RAAD Entered into database software Database Coordinators receive medical records from facilities Sent on encrypted disc Tracking information entered into database Review Results received in RAAD RNs review all over- and underpayments Initial reviews are sent to medical director for any additional input RNs write all levels of appeal Level one appeals are written at ALJ level (82% success rate at level one) Appeal Templates Library of evidence-based references 6 2

3 UM TEAM HIM FINANCE RAC TEAM 7 RAC Team sends to UM Department. UM Department divides denials amongst the UM nurses. The UM nurses research and discuss denied cases with a physician- The UM nurse write 1 st level appeal letter. Physician writes a separate attestation. 8 Redetermination RAC TEAM received Redetermination. RAC TEAM writes 2 nd level appeal. RAC TEAM sends appeal plus physician attestation to MAXIMUS. 9 3

4 Physician Advisors Director of UM Dept. Manager of RAC TEAM We meet to discuss 2 nd level denials and whether to continue to ALJ or Rebill for Part B. 10 Denial Decide to appeal or split bill Track Denied MAXIMUS claim RAC TEAM splits denied inpatient bill into 13X and 12X bills. RAC TEAM works with Revenue Cycle to process the claims. RAC TEAM makes numerous calls to NGS regarding processing problems. UM Nurse writes ALJ Letter RAC TEAM sends ALJ letter FED EX and sends cc d parties certified mail. 11 Get right to the point This patient required an inpatient admission BECAUSE. We disagree with the RAC denial because.. Tables Regulatory information Quotes from Medicare Benefit Policy Manual, Limitation of Liability, etc. Coding clinics, reference articles Direct quotes from physician documentation On page of the medical record the physician stated. 12 4

5 13 Point out the obvious (to us anyway) The decision to admit this patient was a complex medical decision. The decision to admit this patient was made by the physician at the time looking forward. Physicians can consider only the medical evidence that is available at the time of the admission decision. Physicians are not in the position at the time of admission to take into account other information such as test results/uncomplicated recoveries that become available after the admission decision has been made. Furthermore, the reviewer is at an immediate disadvantage because they have never personally examined the beneficiary. These reviewers must piece together findings and observations made by the very same professionals who were on the scene examining and caring for the beneficiary and who were unquestionably in the best positiontocertify thenecessity of thehospital stay. 14 If the patient does NOT meet InterQual(or Milliman) Questionable if this even really matters Don t base your whole argument on InterQual/Milliman criteria, National Government Services has been known to justify their reason for denial as this stay does not meet InterQualcriteria for inpatient admission. We offer the following: Per McKesson InterQualLevel of Care Criteria, in the Notice section, it states: The Criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient. (This verbiage varies a bit based on the year) Furthermore, just because a procedure is not on the inpatient only list, does not mean that the procedure must be performed on an outpatient basis. The determination of status is left to the discretion of the treating physician. Also, when this case occurred in xxxxxx, these procedures were just transitioning from the inpatient to the outpatient setting. The standard of care at that time in this area and most of the country was inpatient status. 15 5

6 Date HHS OMHA Centralized Docketing 200 Public Square, Suite 1260 Cleveland, OH Re: Request for ALJ Hearing Re: Request a teleconference Medicare Appeal Number 1-XXXXXXX Dear Judge: Wheaton Franciscan Healthcare- XXX Hospital (the Appellant ) is appealing the decision of MAXIMUS Federal Services, the Qualified Independent Contractor ( QIC ) retained by the Centers for Medicare and Medicaid Services ( CMS ) to review second level appeals with respect to the services provided to the beneficiary described below. We will demonstrate that QIC erroneously denied Appellants appeal and has failed to follow laws, regulations and the statement of work applicable to the RAC. Appellant has clearly demonstrated in its brief set below the following: Appellant has provided appropriate and medically necessary inpatient services to the beneficiary for which it is entitled to Part A reimbursement Appellant is clearly entitled to payment in the form of an offset to the RAC s alleged overpayment pursuant to CMS s law and regulations, and pursuant to its Statement of Work 1. The beneficiary s name, address and Medicare health insurance claim number 2. The name and address of the appellant is: 3. The Claim Reference number:, NPI, Provider Number: 4. The dates of service being appealed are: 5. The reasons you disagree with the QIC s reconsideration or another determination being appealed Appellant disagrees with the QIC s determination because it has failed to apply the law, regulations and the terms of the Statement of Work in a manner consistent with the facts set forth below: A. FACTS Beneficiary Diagnosis and Treatment **** RAC Denial On XXXXXX, CGI Federal Inc., the Recovery Audit Contractor (RAC), sent to the Appellant a Review Results Letter identifying the following issue: On XXXXXX, National Government Services, Inc. (NGS), the Part A Intermediary, sent to WFHC-Hospital a demand letter for an overpayment in the amount of $X,XXX. Level 1 Appeal On XXXXXX, the Appellant filed an initial Medicare Redetermination Request Form 1st Level of Appeal with the RAC appealing the denial of the Inpatient Admission. Appellant incorporates by reference its arguments set forth in the 1 st Level of Appeal. On XXXXXX, NGS notified the Appellant that its appeal was denied upholding the RAC s decision. Level 2 Appeal On XXXXXX, the Appellant filed a timely appeal to Maximus Federal Services, Inc. the Qualified Independent Contractor ( QIC ) re-asserting its claims that inpatient services rendered to the Appellant were reasonable and medically necessary. On XXXXXX, QIC denied Appellants appeal on the basis that Appellant s services to the beneficiary were not reasonable and necessary. Appellants Legal Position Appellants documentation and the medical record support that the Appellant provided reasonable and medically necessary care to the beneficiary with respect to the beneficiary s inpatient status. 16 Watch the due dates- when you miss a timeline, the appeal is dead. Research the reason for the denial- Don t just take the auditor reason for denial as the end result. However, it does help to point out in your appeal specifically why you disagree with the RAC, FI or QIC s denial, especially at level 3. Use you Physician s to help support the denial. Many times the nurse who denied the claim did not have a complete understanding of the diagnosis, side effects of meds.. When you call the help center get a ticket number. Call back to follow up on the progress. Remember that the auditors are just regular people who have been instructed on a half full/half empty interpretation. At the ALJ level you will be able to state your hospital s side of the story. 17 BE PREPARED! The judge s assistant or secretary will be your friend, correspond with him or her as much as possible Ask for a copy of the exact Judge s files to be securely ed Be well versed in why you disagree with the RAC, MAC and QICs denials.this is a huge focus for the ALJ Have a copy of ALL the correspondences and medical record. Tab your pages. You don t want to be leafing through the medical record to try and find something. This can make some noise and be a distraction. Prepare a cheat sheet with important facts that you want to point out and state where they can be found in your record (specific pages). Decide who will be addressing the Judge and who will be leading hearing for your side. (We had a wonderful attorney who helped us with this process.) Develop a script and explain to the judge that this person will be talking about.and then (name person) will be talking about. Address the judge as Judge or Your Honor Do not speak unless addressed! Brush up on a few Manual references and have them slip off of your tongue easily- If the RAC, NGS, or CGI will be in attendance don t let that rattle you. Ask the Judge prior to the hearing who else will be attending and for a copy of any additional documentation. (The Judge sent us a copy of the sheet that the CGI attorney submitted. We were able to look up the physician to see his specialty and we reviewed the document that they submitted.) If the other side is present, write down anything that you disagree with. You can give this to the person who is leading the hearing. It would be helpful if you were able to site why you disagreed. Ex. The vital signs were not stable- page 2 of ED report or the patient was not pain free- page 2 ED report and page 4 of MD progress note. If this is a teleconference, you can pass notes (but this may distract the person speaking). Depending on the situation and the judge, you are able to submit additional evidence at the ALJ level, but make sure the information is essential to your case. Do NOT inundate the judge with petty documents that are insignificant to the case. You will send in a list of people and their credentials of who will be attending the hearing. I do not recommend a videoconference. (This may not be an option anymore.) 18 6

7 19 Follow the CR 8185 closely!! Call NGS with questions!! Research the process and the number of days it takes for your claims to get to EDS. (It may go thru a clearinghouse and take an additional 1-2 days before it reaches NGS.) Try to split the claim into 12X and 13X early. Don t wait until day 180 to rebill. Sometimes one of these claims might get caught up in the system and you need to release the other to be timely. This may cause one claim being denied. Monitor FISS (Fiscal Intermediary Shared System) for the claim status of 12X and 13X rebill and the date. If a claim is RTP d back to you and you fix it (remove the lab or revenue code from the claims), in FISS the receipt date changes and may lead to an untimely denial. At Wheaton, we check FISS daily. (Watch for RTP d claims.) 20 Watch for the reason the rebill was denied: Untimely denial- Count the days from the last denial. There should be = or <185 days ( days for mailing) Adjust the denied claim: Copy the claim (so that you know what was billed) On each line you need to DDDD over each revenue code and when at the bottom of the page then hit home and enter. (This erases any hidden message with that line.) Then move non-covered to covered (take the info from your copy of denied claim). Place D9 in condition code, OT in adjustment reason, check ATT Physician name and OPR Physician name not blank and in notes section write: Please bypass timely filing because CR8185 states the date of receipt of a determination, decision or notice is presumed to be five days from the date of the determination, decision or notice, unless there is evidence to the contrary. Due date should be 180 days plus 5 days this would bring our due date to xx/xx/xx. 21 7

8 When a claim is denied untimely because the due date falls on a Saturday, Sunday, federal non-workday or legal holiday: Per Pub , Chapter 1, Section (Whenever the last day for timely filing of a claim falls on a Saturday, Sunday, Federal non-workday or legal holiday, the claim will be considered filed timely if it is filed on the next workday.) Please bypass timely filing. 22 When an entire claim has been denied due to one item being a duplicate or a modifier was missing on one line and the claim was filed timely, but due to fixing the problem now the claim is denied untimely This claim was submitted timely and accepted into CMS s electronic temporary storage location. Per Pub 100-4, Chapter 1, The FIs should take the following actions upon receipt of incomplete or invalid submissions: If a not required data element is accurately or inaccurately entered in the appropriate field, but the required data elements are entered accurately and appropriately, process the submission. This entire claim denied due to a not required data element -XXXXX (one duplicate lab). Per the Medicare Manual, the FI should process the claim if the required data elements are entered accurately and appropriately. The basic requirements per 42CFR424.32(a)(1) states, A claim must be filed with the appropriate intermediary or carrier on a form prescribed by CMS in accordance with CMS instructions. The required data elements were entered accurately. Please review this claim and process for payment Lab edit Send to in-house coder (usually need to add modifier 91) 82550, 82553, 80048, 84484, (Usually need to unbundle and make 2 lines) Copy the claim. DDDD revenue code only on denied line, hit home, and enter. Re-key lab information and change to 1 unit On the line with the second unit place modifier 91 (not modifier 59) 38038, Duplicate Call NGS 1 st and ask why it was denied. (Many claims from June-Sept. were denied in error.) Get a ticket number and monitor. NGS will send the claim back for review. 24 8

9 ACCOUNT NO. HIC # PT FIRST NAME PT LAST NAME CLAIM STATUS ADR DATE DATE SENT FOR REVIEW DATE SENT TO CODER ADJUDICATION DATE DUE TO NGS TARGET DATE REQUESTED 12 x CLAIM RELEASED 12X STATUS 13x CLAIM RELEASED 13X STATUS CLAIM 121/131 NOTE Patient Refund Amount Insurance Refund Amount Insurance 25 9