1 Dont Be In Denial! Jeanne Ciocca, Lahey Health and Medical Center 2 Success does not consist in never making mistakes but in never making the same one a second time. George Bernard Shaw oIf you change nothing, nothing will change Jeanne Ciocca, Lahey Health and Medical Center 3 No finger pointing! Jeanne Ciocca, Lahey Health and Medical Center 4 Top PFS Denials
$504,137 $1,098,524 $459,457 $ 7,985,413.16 Jeanne Ciocca, Lahey Health and Medical Center 5 Month to Month Aug-16 Billing Error Bundled Coding COB Duplicate Insurance Eligability Medical Necessity Missing Info Non-Covered Timely Filing Total Jul-16 Jun-16 May-16 Apr-16
$0 $2,000,000 $4,000,000 $6,000,000 $8,000,000 $10,000,000 Jeanne Ciocca, Lahey Health and Medical Center 6 From Month to Month Variance from April to August was $5,755,328. COB drop in Aug 2016 due to removal of Beverly Hospital IME denials (nonteaching hospital) August 2016 decrease in Medical necessity was due to Kyphoplasty as well as cardiac catherization denials which processed for payment. Jeanne Ciocca, Lahey Health and Medical Center 7
All Denials All Payers Denial Category Authorization Benefit Exclusion Billing Error CDM/Charge Issue Coding Coordination of Benefits Credentialing Data Conflict Duplicate Eligibility/Registration Insurance Eligibility Level of Care Medical Necessity Missing Information Non-Covered Past Timely Filing Plan Guidelines Referral Grand Total Apr May Jun Jul Aug $3,147,515$2,775,905$2,818,828$2,515,607$2,252,192 $2,384,458$3,536,758$3,549,161$2,983,543$2,564,904 $54,991 $56,711 $179,343 $59,562 $114,856 $2,208,053$2,813,034$2,070,335$1,487,130$1,232,963
4 5 $1,473,955 $96,313,700 $6,847,476 $5,385,433 $14,328 $33,400,228 $84,972,448 $119,248,859 $13,681,315 $2,222,708 $343,961 $511,401,964 Jeanne Ciocca, Lahey Health and Medical Center 8 Top 10 Denials Non-Covered 2. Duplicate 3. Missing Information 4. Authorization 5. C.O.B. 6. Medical Necessity 7. Coding 8. Billing Error 9. O.T.L (over the filing limit) 10. Insurance Eligibility 1.
Jeanne Ciocca, Lahey Health and Medical Center 9 Decisions to Make o o o o o Modify the claim Appeal Balance Bill Patient Write off DO YOUR HOMEWORK! Jeanne Ciocca, Lahey Health and Medical Center 10 Tools and Resources Review the payer policy and billing regulation M.U.E. Medically Unlikely Edits (charge unit) L.C.D. Local Coverage Determinations (Diagnosis code)
Federal Register N.C.D National Coverage Determination O.C.E. Outpatient Code Editor Optum Revenue Cycle Pro Jeanne Ciocca, Lahey Health and Medical Center 11 Modifying the Claim Timely and efficient, Determine what is missing and fix it online if possible. Modifier Diagnosis Billing codes, Condition, Occurrence, etc. Charging issues Eligibility issues LCD MUE Jeanne Ciocca, Lahey Health and Medical Center
4 Medicare Appeals First Level of Appeal: Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare Administrative Contractor (MAC). 120 days from receipt of denial Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC) 180 days from Re-Determination. 60 days from re-Consideration Third Level of Appeal: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals. 60 days from Re-consideration Fourth Level of Appeal: Review by the Medicare Appeals Council. 60 days from receipt of ALJ decision Fifth Level of Appeal: Judicial Review in Federal District Court. 60 days of receipt of the Medicare Appeals Council's decision Jeanne Ciocca, Lahey Health and Medical Center 13 Appeals first level DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare
redetermination request form 1st Level of appeal name:______________________________________________________________________ Medicare number: _______________________________________________________________________ Item or service you wish to appeal: _________________________________________________________ Date the service or item was received: _______________________________________________________ Date of the initial determination notice (please include a copy of the notice with this request): Beneficiarys (If you received your initial determination notice more than 120 days ago, include your reason for the late filing.) Name of the Medicare contractor that made the determination (not required): 5b. Does this appeal involve an overpayment? Yes No (for providers and suppliers only) I do not agree with the determination decision on my claim because: Additional information Medicare should consider: 5a. 8. I have evidence to submit. Please attach the evidence to this form or attach a statement explaining what you intend to submit and when you intend to submit it. You may also submit additional evidence at a later time, but all evidence must be received prior to the issuance of the redetermination. I do not have evidence to submit. 9. Person appealing: Beneficiary Provider/Supplier Representative
Name, address, and telephone number of person appealing: ______________________________________ Signature of person appealing: _____________________________________________________________ Date signed:____________________________________________________________________________ Jeanne Ciocca, Lahey Health and Medical Center 14 Appeals second level Medicare reconsideration request form 2nd Level of appeal
Beneficiarys name:______________________________________________________________________ Medicare number: _______________________________________________________________________ Item or service you wish to appeal: _________________________________________________________ Date the service or item was received: _______________________________________________________ Date of the redetermination notice (please include a copy of the notice with this request): (If you received your redetermination notice more than 180 days ago, include your reason for the late filing.) 5a. Name of the Medicare contractor that made the redetermination (not required if copy of notice attached): 5b. Does this appeal involve an overpayment? Yes No (for providers and suppliers only) I do not agree with the redetermination decision on my claim because: Additional information Medicare should consider: 8. I have evidence to submit. Please attach the evidence to this form or attach a statement explaining what you intend to submit and when you intend to submit it. You may also submit additional evidence at a later time, but all evidence must be received prior to the issuance of the reconsideration. I do not have evidence to submit. __________________________________ Jeanne Ciocca, Lahey Health and Medical Center 15 Part A J14 Reopening form
Part A Clerical Error/Omission Reopening Request Form
Please use for Part A only (claims processed in FISS) Beneficiarys name: __________________________________________________________________ Medicare number: ________________________________________________________________________ Date of the initial determination notice: _______________________________________________ Date of service: _____________________________________________________________________ The provider requests to change the following clerical error/omission: From a diagnostic test to a screening test From a screening test to a diagnostic test From HCPCS _____________ to HCPCS _____________ because a number was transposed From diagnosis code _____________ to diagnosis code _____________ because a number was transposed Other: __________________________________________________________________________ ___________________________________________________________________________ Remember to attach supporting documentation. Requesters Name (please print): ______________________________________________________ Requesters Address: ________________________________________________________________ ________________________________________________________________ Requesters Telephone Number: ______________________________________________________ Requesters Relationship to the Beneficiary:____________________________________________ Requesters Signature: _______________________________________________________________ Date Signed:_______________________________________________________________________
Jeanne Ciocca, Lahey Note: Anyone who misrepresents or falsifies essential information requested by this form Health may upon conviction be subject to fine or imprisonment under federal law. and Medical Center 16 Example MUE template Medicare Reconsideration Request 2nd Level of Appeal April 15, 2016 John Doe ICN #:21534200243104MAA Redetermination Appeals Number: 01160263068000 Patient:
Maximus Federal Services Part A East 3750 Monroe Ave, Suite 701 Pittsford, NY 14534-1302 Medicare Gentlemen/Ladies: I cared for John Doe at Lahey Hospital and Medical Center for Myelopathy caused by Dural AV Fistula. It is my understanding that Medicare has denied payment for the charges associated with the INR Spinal Angiogram and related procedures (75705, 36215, and 36245) due to the units of service in excess of the MUE (Medically Unlikely Edits) threshold for these procedures. This 59 year old male patient presented with progressive myelopathy. The patient initially had spinal angiogram which demonstrated the lead he had a spinal dural arteriovenous fistula and it was embolized on August 24, 2010. The patient had recurrent symptoms; therefore, repeated spinal angiogram was done on December 9, 2010 which showed recanalization of the previous embolized AV fistula through the small collateral branches and the patient was sent for surgical clippings and disconnection of the draining vein. The patient had significant improvement; however, recently he stated that he was having more symptoms of numbness and occasional weakness. Mr. Doe came back for repeated spinal angiogram and reevaluation of his dural arteriovenous fistula of right T7. This lesion was previously treated successful by an embolization followed by surgical clipping. I
have reviewed the claim submitted by the hospital to Medicare and find that it was properly coded and accurately represents the services rendered to this patient. I further assert that the services rendered and billed on this claim were medically necessary and reasonable and in accordance to accepted standards of medical care. The number of procedures performed was necessary and justified in order to rule out any possible new dural AV Shunt or recurrent AV shunt. Please overturn the original decision to deny payment for these medically necessary services. Sincerely John Lahey, M.D. Jeanne Ciocca, Lahey Health and Medical Center 17 Appeal Level Criteria Attachment s Response Redetermination
120 days from denial Request form Claim form Supporting Docs If unfavorable Medicare will advise what is missing. Re-file second appeal if appropriate. 60 day turn around Reconsideration First unfavorable Example, missing docs; progress note, history, physical
1st decision letter Enclose missing records Request form If un-favorable No supporting documents No coding update No addendum 60 day turn around Write off or pursue ALJ Hearing Hospital error only, MUE units, dx etc. Reopening form
Indicate correction, Should have response within 60 days Medicare Appeal Process Part A J14 Re-Opening Jeanne Ciocca, Lahey Health and Medical Center 18 Adjustment Claims in FISS o o o o Submit an Adjustment to Correct Claims Partially Denied by Automated LCD/NCD Denials Process designed to correct diagnosis codes based on LCD or NCD
Cannot be used to add charges or change HCPC codes If all lines denied (status D) can not adjust in FISS Jeanne Ciocca, Lahey Health and Medical Center 19 How to Adjust in FISS Electronic 837 claims FISS/DDE Provider Online System Use condition code D9 Add remarks Enter LN in the Adjust Reason Code Add the diagnosis code ( ensuring the diagnosis is appropriate for the beneficiary and supported in the medical record) Use condition code D9 Add remarks Make the charges and units covered Add the diagnosis code making sure the diagnosis is appropriate for the beneficiary and supported in the medical record Enter LN adjust in the 2300 BILLING NOTE
(NTE) segment NTE02 data element where the NTE01 data element equals ADD Delete the denied line and re-enter charges as covered Jeanne Ciocca, Lahey Health and Medical Center 20 ICD10 Documentation - LCD Does your documentation support ICD10 Are your claims coded to the highest specificity Are you being reimbursed correctly Do you accept NO for an answer Coordination with HIM Develop relationship with Physicians Jeanne Ciocca, Lahey Health and Medical Center 21 Communication Trail Denial Received Review the cpt in the LCD policy Review the record
Send for re-code (Health Information Services) If no re-code Contact the Physician for review Educate on LCD policy Jeanne Ciocca, Lahey Health and Medical Center 22 Communication Trail continued Physician response Was the procedure documented to appropriately to describe the procedure or treatment. If not; request the physician to do an addendum to the record Review LCD language Send back to HIM coding
If coding update, adjust the claim is FISS If no coding update, begin appeal process Jeanne Ciocca, Lahey Health and Medical Center 23 LCD Overturned Denials o Interventional Neuroradiology o o Kyphoplasty Cardiology o Catheterization Lab o o o Heart Catheterization Coronary Artery Angiogram Myocardial perfusion imaging Jeanne Ciocca, Lahey Health and Medical Center 24
LCD Overturned continued High end drugs (infusions) Darbopetoin (J0881) Infliximab (J1745) Xolair (J2357) Ibandronate (J1740) Off label drug usage Jeanne Ciocca, Lahey Health and Medical Center 25 Medically Unlikely Edits (MUE) Implemented JANUARY 1, 2007 Developed by CMS to reduce claim processing errors on part B claims. Charge entry errors do occur particularly in drug dosages. Verify if units are incorrect Verify the Physician order Jeanne Ciocca, Lahey Health and Medical Center
26 MUE Adjudication Indicator (MAI) MAI 1 indicates a value applied at the line level. MAI 2 indicates a value that was determined based on absolute criteria, such as anatomic considerations MAI 3 indicates a value that is unlikely to appear on a correctly coded claim but could, in unusual circumstances, be payable Jeanne Ciocca, Lahey Health and Medical Center 27 MUE Checklist Review if CPT is correct Review that the CARC code is 151 (Payment adjusted because the payer deems the information submitted does not support this many/frequency of services). Review the threshold for MUE What is the MAI code on the MUE, 1,2 or 3 Confirm the Revenue Integrity Jeanne Ciocca, Lahey Health and Medical
Center 28 Decision to Appeal Copy the policy with MUE threshold Records to substantiate the MUE Physician statement if needed The MAI needs to be from column 1 or 3 Jeanne Ciocca, Lahey Health and Medical Center 29 Sooner vs. Later Keep a close watch on your 0-30 aging buckets. Monitor all large balances 25K>, ensure processing each month. Verify all denials are worked through completion by Friday of each week. Track and Trend Jeanne Ciocca, Lahey Health and Medical Center 30 Times have changed
We are no longer the department of corrections. Know your payer its billing regulation and policies If your Right, push back and dont take no for an answer Educate physicians and coders on policies Jeanne Ciocca, Lahey Health and Medical Center 31 Times have changed continued Overturn the denial with coding changes and documentation addendums if possible Appeal if necessary Education will prevent future denials Jeanne Ciocca, Lahey Health and Medical Center 32 April to August 2016 Patient Financial Services began to push
back Forty seven (47) large dollar claims were overturned. Of these only four (4) were appealed. Total overturned $1,125,698 PFS Medicare denials dropped $5,755,328 Jeanne Ciocca, Lahey Health and Medical Center 33 References https:// www.cms.gov/medicare-coverage-datab ase/overview-and-quick-search.aspx https:// www.cms.gov/Medicare/Coding/National CorrectCodInitEd/MUE.html https://www.ngsmedicare.com https:// www.cms.gov/Medicare/Coding/National CorrectCodInitEd/NCCI-Coding-Edits.html Jeanne Ciocca, Lahey Health and Medical Center 34
Questions Jeanne Ciocca, Lahey Health and Medical Center
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