1. Don’t Be In Denial!
Jeanne Ciocca, Lahey Health and Medical Center

2. “If you change nothing, nothing will change”
“Success does not consist in never making mistakes but in never making the same one a second time.” ― George Bernard Shaw
“If 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 (Medicare)
Denial Category
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Billing Error
$314,165
$1,471,055
$963,353
$1,198,862
$395,743
Bundled
$79,942
$158,010
$95,755
$75,700
$64,159
Coding
$1,387,020
$643,945
$691,416
$189,573
$374,334
COB
$2,815,046
$2,816,034
$2,734,688
$112,773
$90,242
Duplicate
$1,527,490
$1,929,228
$1,698,732
$1,106,785
$1,317,092
Insurance Eligibility
$206,508
$312,243
$225,616
$191,588
$81,362
Medical Necessity
$734,606
$590,337
$504,137
$1,098,524
$459,457
Missing Info
$1,160,769
$198,157
$236,545
$172,247
$116,952
Non-Covered
$862,752
$880,518
$788,922
$776,167
$435,766
Timely Filing
$9,253
$46,249 $0
$18,393
Total
$ 9,108,828.49
$ 9,008,779.24
$ 7,985,413.16
$4,922,218
$3,353,500
Jeanne Ciocca, Lahey Health and Medical Center

5. Month to Month
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 (non-teaching 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 Grand Total Reflects FY 2016
Denial Category
Apr
May
Jun
Jul
Aug
Authorization
$3,147,515
$2,775,905
$2,818,828
$2,515,607
$2,252,192
$42,377,188
Benefit Exclusion
$1,636,976
Billing Error
$2,384,458
$3,536,758
$3,549,161
$2,983,543
$2,564,904
$27,380,530
CDM/Charge Issue
$54,991
$56,711
$179,343
$59,562
$114,856
$2,098,139
Coding
$2,208,053
$2,813,034
$2,070,335
$1,487,130
$1,232,963
$29,912,911
Coordination of Benefits
$3,547,972
$3,627,727
$3,586,280
$3,025,223
$2,731,660
$38,216,338
Credentialing
$554,938
$520,815
$780,132
$453,027
$343,579
$5,875,472
Data Conflict
$1,473,955
Duplicate
$8,512,125
$7,789,912
$6,248,133
$7,196,307
$5,669,390
$96,313,700
Eligibility/Registration
$6,847,476
Insurance Eligibility
$484,629
$553,920
$444,530
$438,288
$524,268
$5,385,433
Level of Care
$14,328
Medical Necessity
$1,858,877
$1,371,135
$1,473,745
$2,240,649
$1,563,164
$33,400,228
Missing Information
$7,306,315
$5,732,336
$6,743,188
$5,756,033
$6,061,742
$84,972,448
Non-Covered
$6,341,778
$7,328,486
$6,866,737
$5,343,894
$4,938,810
$119,248,859
Past Timely Filing
$1,352,481
$1,855,653
$1,609,153
$1,358,462
$1,294,427
$13,681,315
Plan Guidelines
$2,222,708
Referral
$343,961
Grand Total
$37,754,133
$37,962,392
$36,369,565
$32,857,724
$29,291,955
$511,401,964
Grand Total Reflects FY 2016
Jeanne Ciocca, Lahey Health and Medical Center

8. Top 10 Denials Non-Covered Duplicate Missing Information Authorization
C.O.B.
Medical Necessity
Coding
Billing Error
O.T.L (over the filing limit)
Insurance Eligibility
Jeanne Ciocca, Lahey Health and Medical Center

9. Decisions to Make 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

12. 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
Taken from CMS website. Please take into consideration the length of time to file an appeal
PFS to date has not filed an appeal to the ALJ, These have been filed for RAC denials only
no 4th and 5th level appeal has been filed
Jeanne Ciocca, Lahey Health and Medical Center

13. Appeals first level Jeanne Ciocca, Lahey Health and Medical Center
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
Medicare redetermination request form — 1st Level of appeal
Beneficiary’s 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):
(If you received your initial determination notice more than 120 days ago, include your reason for the late filing.)
5a. 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: 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 Jeanne Ciocca, Lahey Health and Medical Center
Medicare reconsideration request form — 2nd Level of appeal
Beneficiary’s 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)
Beneficiary’s 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.
Requester’s Name (please print):
______________________________________________________
Requester’s Address:
________________________________________________________________
Requester’s Telephone Number:
Requester’s Relationship to the
Beneficiary:____________________________________________
Requester’s Signature:
_______________________________________________________________
Date
Signed:_______________________________________________________________________
Note: Anyone who misrepresents or falsifies essential information requested by this form may
upon conviction be subject to fine or imprisonment under federal law.
Jeanne Ciocca, Lahey Health and Medical Center

16. Jeanne Ciocca, Lahey Health and Medical Center
Example MUE template
Medicare Reconsideration Request — 2nd Level of Appeal
April 15, 2016
Patient: John Doe
ICN #: MAA
Redetermination Appeals Number:
Maximus Federal Services
Medicare Part A East
3750 Monroe Ave, Suite 701
Pittsford, NY
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, 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. Medicare Appeal Process
Appeal Level
Criteria
Attachments
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 un-favorable
Example, missing docs; progress note, history, physical
1st decision letter
Enclose missing records
If un-favorable
No supporting documents
No coding update
No addendum
Write off or pursue ALJ Hearing
Part A J14 Re-Opening
Hospital error only, MUE units, dx etc.
Reopening form
Indicate correction,
Should have response within 60 days
Jeanne Ciocca, Lahey Health and Medical Center

18. Adjustment Claims in FISS
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
3 day turn around
Jeanne Ciocca, Lahey Health and Medical Center

19. How to Adjust in FISS Direct from NGS Medicare portal
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)
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
Direct from NGS Medicare portal
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
Interventional Neuroradiology
Kyphoplasty
Cardiology
Catheterization Lab
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
National Correct Coding Initiative (NCCI) policy manual
ng-Network-MLN/MLNProducts/downloads/How-to-Use-NCCI-Tools.pdf
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 it’s billing regulation and policies
If your Right, push back and don’t 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
Jeanne Ciocca, Lahey Health and Medical Center

34. Questions
Jeanne Ciocca, Lahey Health and Medical Center