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Case Management/UR Denials and Appeals

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Presentation on theme: "Case Management/UR Denials and Appeals"— Presentation transcript:

1 Case Management/UR Denials and Appeals

2 Agenda Denials Management – RAC, MAC, ZPIC, etc.
Preventing RAC Denials Successful Appeals Strategy

3 Denials Management

4 Total Corrections (Millions)
CMS RAC Stats Total Corrections (Millions) October 2009 – September 2010 FY 2010 $92.3 October 2010 – September 2011 FY 2011 $939.33 October 2011 – September 2012 FY 2012 $2,400.7 October 2012 – September 2013 FY 2013 $3,834.8 October 2013 – September 2014 FY 2014 $2,404.6 Total National Program $9,671.7

5 Region C: Connolly Stats
Underpayments Collected (Millions) Underpayments Returned (Millions) Total Quarter Collections FY To Date Collections Region C: Connolly $92.34 $9.33 $17.71 $394.01

6 RAC Update Two mid-night delay in enforcement was lifted 3/31/15
Probe & Educate ended 3/31/15 CMS has re-contracted with existing recovery auditors 3/31/15 MACs will no longer be limited to chart pull limits when reviewing claims for patient status 3/31/15

7 New Rules – Be Careful Moratorium ended 3/31/15.
Patient status reviews began 4/1/15 10/1/13 through 3/31/15 are excluded from review for patient status They are NOT excluded from review for medical necessity, NCD/LCD, documentation, and other approved issues

8 New Rules – Be Careful Gaming the System
Comprehensive Error Rate Testing (CERT) First-Look Analysis for Hospital Outlier Monitoring (FATHOM) Program for Evaluating Payment Patterns Electronic Report (PEPPER)

9 FATHOM FATHOM: First-Look Analysis Tool for Hospital Outlier Monitoring is a Microsoft Access application that allows CMS to provide each State with hospital-specific Medicare claims data statistics, which identify areas having high payment errors. These target area statistics serve as relative indicators of payment errors. FATHOM reports include: short-term acute care inpatient prospective payment system (IPPS) hospitals (ST FATHOM), long-term acute-care IPPS hospitals (LT FATHOM), CAHs, IRFs and IPF. FATHOMs contain administrative data extracted from the Standard Data Processing System data warehouse for three previous fiscal years (FYs) and the current FY to date (cumulative).

10 Review of Two Midnight rule “CMS-1599 F”
NOT JUST FOR MEDICARE ADMISSIONS Inpatient Admission Order Signed/authenticated prior to discharge Physician Certification Separately signed no longer required Medical Necessity Expectation of a Two-midnight Stay

11 Review of Two Midnight rule “CMS-1599 F”
Exclusions Patient’s Procedure in on the Inpatient Only List from CMS Patient left AMA(Against Medical Advice) Patient expired Patient newly elected Hospice Patient transferred to another acute care hospital Patient unexpectedly improved

12 Two Midnight rule “CMS-1599 F”
While CMS is saying to just have physician sign inpatient orders for 2 midnights, you still need to ensure medical necessity. You must ensure that you have sufficient documentation. You must have a consistent and 100% compliant method to get the CMS approved inpatient order, whether in CPOE or on paper. You should audit to minimize your risk of future denials.

13 Two Midnight rule Denial Results MAC
Most Current Data Results 27% Denial Rate Denial Reasons 37% missing, unsigned, invalid order 63% failed to document 2 midnight expectation PROBE Results 30-60% based on sample size of 10

14 2-Midnight Rule What is your facility’s PLAN? Written procedures for
Case Managers Physicians Patient Access (Registration) Reps PFS Medicare Billers Consider CM – Physician “team” for inpatient documentation!

15 2-Midnight Rule Consider pre-bill edit to hold Medicare inpatient claims that are one-day stays. Case Manager or Nurse Auditor Review prior to billing Take specific deficiencies in documentation and LOS back to physician for review (ideally, back to CM – Phys team)

16 Preventing RAC Denials

17 Not Just for Acute Care Providers
Denials are affecting all organizations along the continuum of care Hospice Home Health DME Inpatient Rehab LTAC

18 Best Practices Centralized Function
Multi-Disciplinary Team Consisting of: RN/Case Managers Physician Advisors Coders Billers Revenue Integrity Clerical Systematic Methodology to approach appeal process

19 Best Practices - Continued
Flow charted process Role Clarity State of the Art Software System Easy to use Has powerful reporting capabilities Alerts to ensure deadlines are met Dollars at risk vs. dollars lost

20 Best Practices - Continued
Focus should be on determining the root cause and putting preventative measures in place Requires support at highest level and process changes in many facets of the organization

21 Change Physician Behavior
Physicians are scientists Provide hard facts and data Evidenced based Medicine Physicians do not like to be outliers Leave emotion and finances out of discussions

22 Denials Management Are you monitoring your metrics?
Who is responsible? Have you flowcharted the processes? Have you assigned responsibility? How do you track deadlines? Who determines if a denial is worth the appeal cost? How is that determined?

23 Denials Management Do you use an external company? Is the cost worth it? Are you paying a contingency or flat fee? How do you track denials so you can determine root causes and implement improvement processes? MedPerformance has a system to help you.

24 iMAD Denial Management Program iMAD = interactive MedPerformance Appeals and Denials

25 iMAD - Main Menu

26 iMAD – Patient Information

27 iMAD – Due Dates

28 iMAD – Standard Reports

29 Successful Appeals Strategy

30 The Appeal Process Appeal process
Intentionally complex and deceptive process…. Hard deadlines Labor intensive Allow recoupment or risk interest

31 Successful Appeals Strategy
Must have tool to track denials and deadlines Need guidance from Executives If a medical necessity denial – paint a clear picture of patient Include only abnormal data Include what is being done that can only be done in an acute care facility

32 Questions/Comments? Rebecca Corzine Tarr Owner MedPerformance LLC (813) 32

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