Revenue Cycle State of the State

Revenue Cycle State of the State
Where are we? How can we fight delays and denials?

Agenda focalPoint Data Set The Revenue Cycle: Where Are We? Denials
Accounts Receivable Aging Days to Pay Days to File Collection Rates/ Contractual Adjustments Top Tens Profiling Denials Denial Rates Top Denial Codes What To Do???

Disclaimer If you did not attend this presentation live, misinterpretations of the data may occur. Please check with your payers for billing polcies for each claim. CPT codes and descriptions only are copyright 2016 American Medical Association (AMA). All rights reserved. The AMA assumes no liability for data contained or not contained herein. All Medicare information is derived from published rules; however, interpretations may be erroneous and typos may be evidenced. It is mandatory that coding and billing is based on information derived from each practice or clinic. This is not legal or payment advice. This content is abbreviated for Medical Oncology. It does not substitute for a thorough review of code books, regulations, and Carrier guidance. This information is valid for the date of presentation only. This presentation should not be reproduced without the permission of the author and is time sensitive Put in a separate page for web sites of regulations

Our Data Source FocalPoint 2016 Data Represents 165+ Cancer Centers, 725 sites of service, 478 payers and 2,300 Hematologists and Oncologists Metrics 2016 Total Payer responses to claims (includes submission and resubmissions) 6,679,790 Distinct patients 300,260 Distinct claims 2,127,234

Data Origin Clearinghouse:
The pathway for claims to be dispatched from providers to the payers and from the payers to the providers seamlessly and electronically The electronic repository for data from outgoing claim and incoming payer adjudication decisions. Data collected at this level includes but is not limited to: Payer adjudication response: denial or payment Allowed and payment amounts Patient portions Diagnosis NDC Number Reason for denial or delay Demographic data All community practices, except 6 clinics that are hospital-based but are billing Part B (”Provider-Based”)

focalPoint’s relationship is with the clearinghouse
Clearinghouse: Claims dispatched and processed for payment Payer: Claims Adjudicated Practice: Inbound Remittance ANSI 835 Provider: Outbound Claim ANSI 837

focalPoint Dataset Lifecycle

focalPoint Data Sets Collects data on Does not collect data on
Allowed Amounts Insurance Payment Amounts Non-Reimbursed Amounts Patient Responsibility Days To Pay and Days to File Claims Adjustment Codes (CARCs) which we will refer to herein as denial codes Remittance Advice Remark Codes (RARCs) which we will refer to as Reason codes Does not collect data on Statistics for individual practices, UNLESS requested by the practice Prescribing behavior of providers CPT code Groupings E/M Imaging Radiation Oncology

Regional Settings: See Our Appendices http://onpointoncology
Northeast Region ME, VT, CT, NY, NJ, PA, MD, VA, DC Southeast NC, SC, Florida, ALA, GA, MS, LA Heartland Ark, ILL, WI, MI, ND, TN, IN, OH, KY, NEB, IA, TX West WA, ORE, NM, AZ, NEV, ID, UT, CO, WY, CA CARC Code Table for Everyone!

The Who, Snafus, and Best Practices
Revenue Cycle The Who, Snafus, and Best Practices

The Billing Cycle: Average Office
Pre-Visit Authorization Service/ Order Entry Documentation & Coding Billing Collections Denials/Appeals Remember, resources are essential at every step of the process…

Revenue Cycle: Hospitals

Payer Mix focalPoint Database 2016

Part B Accounts Receivable: Total Across U.S.
Caveats All patient portions not captured in terms of collections All program coverage may not be captured In terms of line items in A/R 0-30 Days = 63.08% 31-60 Days = 18.58% 61-90 Days = 4.51% Days = 2.51% 120+ Days = 11.32% In terms of $ in A/R 0-30 Days = 69.17% 31-60 Days = 14.98% 61-90 Days = 3.97% Days = 2.03% 120+ Days = 9.85%

Part B: Account Aging for IV Drugs 2016 (Insurance Only-Top 25 Payers)

Revenue Cycle Metrics A/R Balance and A/R Days
Measure of overall A/R performance Benchmark for initial payment by insurance = See Previous Slides Billing Work in Process Measure of accounts that are prevented from being billed by cause Prior auth More info: NDC, Diagnosis guidelines, etc. Coding Dictation Audit DTF is a key metric Follow-up Work in Process Measure of accounts that cannot be billed Measure accounts with “delays” (CARC code 15, 16, 251, 252, et al) Measured at unit and individual employee level A/R Aging from Date of Service Measure of aging of accounts; stratified by dollar amount and age Drug claims should be measured from the date that you pay for your drugs (Drug claims > 30 days) Analysis of aged accounts by $ can support staff resource allocation If you are focused on accounts at 120+ days, it’s too late to resolve issues in a timely manner

Revenue Cycle Metrics Cash Factor (Cash/3 month Average Daily Revenue)
Measures the cash momentum by accounting for shifts in revenue Not a good relative measure against other organizations due to contractual differences Collections # of accounts collected per day, week, month by $ size, age, unit, and individual Write-Off % (ABCs) Measure of dollars written off of A/R balance as % of Gross Revenue Improvement in Revenue Cycle performance should focus on Non-Routine Administrative and Bad Debt write-offs Administrative Write-offs Routine Write-Offs: includes discounts, contractual adjustments Non-Routine Write-Offs: includes write-offs for timely filing, billing, eligibility errors Bad Debt Write-Offs Measure of uncollected self pay accounts Typically written off to a collection agency for follow-up PAP and Co-pay’ Write-Offs’ Measure of accounts written off based on program guidelines Track dollar amounts for assistance and no assistance Analysis of write-offs in conjunction with A/R performance prevents achieving A/R reduction goals through increased write-offs

Days to File By Service (With Outliers)-2016
Service Type Days to File E/M 16 days Imaging Radiation 22 days Drugs 13 days ALL SERVICES

Days To Pay 2016 by Service Type of Service Days To Pay E/M 18 days
Imaging 37 days Radiation 28 days Drugs 36 days ALL SERVICES 21 days

Worst Insurance Companies by Days To Pay-IV Drugs (N > 10 claims)

Top Ten Injectable Drugs for Days To Pay--2016
DTP Ibritumomab tiuxetan 67 Situximab for injection 62 Trabectin 49 Elotuzumab 44 Daratumumab 43 Irinotecan liposomal Blinatumomab 41 Sipuleucel-T suspension 39 Ipilimumab 37 Sargramostim 36

Revenue Cycle Step-by-Step
How to PREVENT Denials

Pre-Visit: Medicare Who What Best Practices
“Front Desk” or Hospital Admitting Office Financial Counselor /Patient Advocates Drug Programs What Verification of benefits (MA versus Medicare) Verification of secondary insurance Provision of an ABN for off-label use, even with compendia Best Practices On-line verification of Medicare benefits and plan as necessary

Situations in which an ABN is Required
Whether to issue an ABN depends on provider’s expectation of Medicare payment or denial If provider expects Medicare denial based on any of the following, an ABN should be issued: Medical Necessity Frequency-limited Items and Services Experimental Items and Services Situations in which an ABN is Required Whether an ABN should be given in a particular instance depends on the user’s (that is, the provider’s, physician’s, practitioner’s, or supplier’s) expectation of Medicare payment or denial. If the user expects Medicare to pay, an ABN should not be given. If the user “never knows whether or not Medicare will pay,” an ABN should not be given. If the user expects Medicare to deny payment, the next question is: “On what basis is denial expected?” If Medicare is expected to deny payment, entirely or in part, for the item or service that the provider, practitioner, or supplier furnishes to a beneficiary because it is not reasonable and necessary under Medicare program standards (e.g., “medical necessity denials” under §1862(a)(1) of the Act), the ABN-G or the ABN-L, as appropriate, should be given. This is applicable to all assigned Part B items and services, and to unassigned physicians’ services and medical equipment and supplies. Certain screening tests (e.g., mammography, pap smear, pelvic exam, glaucoma, prostate cancer, colorectal cancer) have frequency limits under §1862(a)(1) of the Act, therefore, §1842(l) and §1879(a)-(c) of the Act apply and ABNs should be given when Medicare denial of payment for frequency is expected for any of these tests. When any item or service which Medicare considers to be experimental (e.g., “Research Use Only” and “Investigational Use Only” laboratory tests) is to be furnished, since all such services are denied as not reasonable and necessary under §1862(a)(1) of the Act because they are not proven safe and effective, the beneficiary may be given an ABN that gives as the reason for expecting denial that: “Medicare does not pay for services which it considers to be experimental or for research use.” Alternative, more specific, language with respect to Medicare coverage for clinical trials may be substituted as necessary as the ABN’s reason for expecting denial. Source: Palmetto GBA MAC 1

Completion of the ABN Requirements: Must use approved Form CMS R-131
Complete header section with patient name and HICN Identify specific item or service Identify specific reason for expected Medicare denial Estimated cost may be provided Patient must personally select Option 1 or Option 2 or Option 3 Beneficiary signature and date Completion of the ABN Patient Name Line: The user enters the name of the patient, not substituting the name of an authorized representative. Medicare Health Insurance Claim Number (HICN) Line: The user enters the patient’s Medicare HICN. An ABN will not be invalidated solely for the lack of a Medicare HICN unless the beneficiary recipient of an ABN alleges that the ABN was signed by someone else of the same name and the Medicare contractor cannot resolve the matter with certainty. Items or Services box: In the section of the ABN-G beginning “We expect that Medicare will not pay for the item(s) or service(s) …,” in the first box “Items or Services”, the user specifies the health care items or services for which he/she/it expects Medicare will not pay. The items or services at issue must be described in sufficient detail so that the patient can understand what items or services may not be furnished. HCPCS codes by themselves are not acceptable as descriptions. The use on the ABN of a list of the items and/or services which the particular user frequently furnishes, with check-off boxes or some similar method of identifying the particular items or services for which denial is predicted, is an acceptable practice. Because box: In the second box “Because” the users give the reason why they expect Medicare to deny payment. The reason(s) must be sufficiently specific to allow the patient to understand the basis for the expectation that Medicare will deny payment. The use of lists of reasons for denial which the particular physician or supplier has found are frequently applicable, with check-off boxes or some similar method of indicating the selection of the reason(s), is an acceptable practice. Estimated Cost Line: The user may provide the patient with an estimated cost of the items and/or services. The patient may ask about the cost and jot down an amount in this space. Users should respond to such inquiries to the best of their ability. The lack of an amount on this line, or an amount which is different from the final actual cost, does not invalidate the ABN. Selection of Option 1 or Option 2: The patient must personally select an option. The user must not pre-select either option. Pre-selection is prohibited and will invalidate the ABN. The Medicare contractor will not accept as evidence of beneficiary notice any ABN on which the user has pre-selected an option. Signature and date: In the “Signature of patient …” blank, the patient, or person acting on his or her behalf, must sign his or her name. In the “Date” blank, the patient, or his or her authorized representative, should enter the date on which he or she signed the ABN. If the date is filled in by the user and the beneficiary or his or her authorized representative does not dispute the date, that date is acceptable. If the beneficiary refuses to sign the ABN but still insists on receiving the services, the “Limitation of Liability” applies to assigned claims, which requires notification but not a signature. In these cases, the ABN should be annotated with the signature of a witness. The claim should be submitted with the GA modifier, and the patient will still be liable for the charge if the claim is denied. Source: Palmetto GBA MAC 1

Delivery of the ABN Must be delivered prior to service rendered
Copy must be provided to beneficiary ABNs should never be delivered to patients in emergency situations. Delivery of the ABN A beneficiary must be notified far enough in advance of an event about which a decision must be made by the beneficiary (e.g., receiving a medical service) so that the beneficiary can make a rational, informed consumer decision without undue pressure. Last minute notification may be perceived as coercive, and a coercive notice is a defective notice. ABN delivery should take place before a procedure is initiated and before physical preparation of the patient (e.g., disrobing, placement in or attachment of diagnostic or treatment equipment) begins. The ABN must be prepared with an original and at least one copy. The notifier must retain the original and give the copy to the beneficiary or authorized representative. (In a case where the notifier that gives an ABN is not the entity which ultimately bills Medicare for the item or service, e.g., when a physician draws a test specimen and sends it to a laboratory for testing, the notifier should give a copy of the signed ABN to the entity which ultimately bills Medicare.) The copy is given to the beneficiary immediately after the beneficiary signs it. Legible duplicates (carbons, etc.), fax copies, electronically scanned copies, or photocopies will suffice. This is a fraud and abuse prevention measure. If a beneficiary is not given a copy of the ABN and if the beneficiary later alleges that the ABN presented to the contractor by the notifier is different in any material respect from the ABN he/she signed, the contractor will give credence to the beneficiary’s allegations. The beneficiary should be fully capable of making an informed decision regarding whether to receive items or services when there is a genuine doubt that Medicare will not pay. In situations where the beneficiary is under great duress, e.g., a medical emergency, it would not be expected that he-she would be able to make such a decision, and therefore, the ABN should not be administered. Source: Palmetto GBA MAC 1

Pre-Visit: Private Insurance
Who “Front Desk” Financial Counselor /Patient Advocates Drug programs What Verification of benefits Verification of coordination of benefits: primary versus secondary Prior Authorization Patient Counseling on OOP Identification of Programs Best Practices Full insurance verification covering each and every aspect of insurance Transfer of full medical record to payer electronically Full assessment of out-of-pocket costs Application to programs

Insurance Verification Check List
Patient has the insurance they say they do and it is primary with effective date Insurance address for bill Plan type: HMO/PPO/other Deductibles impacting care delivered in the office, e.g. IV drugs, radiology, labs, chemotherapy administration Episodic patient cost sharing for care delivered in the office, e.g. flat copays for Rx; coinsurance payments, amount Lifetime, annual or episode out of pocket maximum Catastrophic coverage (yes/no) Benefit caps: lifetime or other If possible, patients’ current status regarding deductibles and out of pocket maximums; current progress toward caps Insurer requirements: Prior authorization; certification; notification; case management, step therapy Specialty pharmacy preference for patient costs, pharmacy billing.

Authorization: All Requiring Plans
Who “Front Desk” Financial Counselor /Patient Advocates Nurses Physicians for peer-to-peer Access Solutions What Prior authorization Best Practices Use correct forms and formats for each payer EMR templates Expedite prior authorization on every drug given in the clinic Don’t take no E-Prior Auth for non-Buy and Bill drugs

Authorization: Private Insurance
Prior authorization Snafus Insurance companies do not provide correct information as to the need for; the responsible organization; or billing format for the PA Practices do not get PA because plan “has never required it” Practices believe pathways mitigate the need for PA PA is granted and more information is requested delaying the claim PA not renewed on time

Documentation/Coding
Who Physicians & NPPs Nurses Coders Billers What Deriving codes from Superbill, CDM, or directly from chart documentation Best Practices Auditing EACH CHART with drug therapy prior to billing for match to documentation and correct coding Revenue loss audit at least once per year

Medical Records/Coding
Symptoms High A/R resulting from inappropriate resources and inaccurate patient care/charge information High A/R resulting manual charge entry from outdated coding information Loss of revenue from lower level coding due to lack of physician documentation/inappropriate interpretation No certified coders in clinics with > 5 providers Common Underlying Issues Physicians do not complete medical records so codes cannot be submitted Hospital visits and consults (for private payers) are a mess Nurses do not think coding is ‘their job’ Physicians cling to low level codes or bill no visits with chemo because of audit fear Potential Solutions Develop backlog reporting of physicians who have unbilled visit reporting Perform account review to determine appropriateness of assigned coding of diagnoses, drug administration, E/M Audit every complex chemo regimen bill before it is submitted

Documentation/Coding: Medicare
Doc/Coding Snafus ICD-10-CM policies for Medicare not always clear or consistent Physician documentation does not match ICD-10-CM codes particularly in RA, NHL, Leukemia (“in remission”) Coding does not match on-label use when drug is given on-label, e.g. NHL, Unbundling—billing for fluids, IV start, port access, etc. Billing waste for BENDEKA or other MDVs Correct units for each J-code—worse in hospitals

Signatures: Review Criteria
Auditors: MACs, CERTs, and RACs, just to name a few. CMS requires that orders for healthcare services and the services that were provided be authenticated by the author using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication. The previous language in the CMS Program Integrity Manual required a “legible identifier”. The 2010 transmittal--- CMS Transmittal 327 has added additional clarification and signature assessment requirements. Any auditor can use this rule, unless other laws or regulations supersede this rule. onPoint Oncology LLC

SIGNATURES: CMS AUDITS
If the signature is missing from any other medical documentation, excluding the order, the reviewer should accept a signature attestation from the author of the medical record entry. Providers should not add late signatures to the medical record “beyond the short delay that occurs during the transcription process” and should instead use the signature attestation process. Other providers in the same group may not attest to the original author’s signature. In addition, if the Medicare policy is “silent” on whether a signature must be dated, the reviewer has been instructed to ensure that the rest of the documentation contains enough information to determine the date when the service was ordered and/or performed. For example, the reviewer finds that the first and third order on a page have a specific date; however, the second order on the same page is not dated. It could be assumed that the second order occurred on the same date. All providers should be reviewing all documentation for dates and signatures in a timely manner and prior to considering the medical record complete. Also, review all request letters for any additional language the reviewer might add reminding you that a signature log or attestation can be submitted with the copies as part of the Additional Documentation Request (ADR). onPoint Oncology LLC

Billing Who What Best Practices “Back Office” Generate the bill
Trace outstanding A/R Perform collections on patient portions May process co-pay program payments Best Practices Are familiar to the letter with the billing parameters of the 20% of payers that make up 80% of payments Have strong write-off and write down policies Average = 30 days for all insurance payments and have no more than 10% of A/R over 90 days

Billing Snafus : Medicare
CMDs establish negative guidelines. Practice ignore them. Get rejections. CMDs state that drug is self-administered based on Section of the Benefit Policy Manual, e.g. try oral before IV. Risks: GHI, FCSO, Trailblazers. So many auditors—MACs, RACs, CERT, OIG, ZPICs Pricing on drugs with no J-code No guidelines but drug is given and rejected on the back end or in an audit as not being medical necessity. Rejection can include the total drug claim or just the drug or administration.

Billing : Private Insurance
Billing Snafus No guidelines but drug is given and rejected on the back end or in an audit as not being medical necessity. Rejection can include the total drug claim or just the drug or administration. How PA is recorded on the claim is variable Too much information is requested after the treatment is authorized For new drugs, just being informed is a snafu and variation of J9999 requirements No formal appeal or telephonic appeal process outlined anywhere

Collections Who What Best Practices “The Back Office”
Collection Agencies What Collection of stubborn insurance claims Collection of patient portions Best Practices Have very tight procedures as to who collects and when Have an excellent financial agreement with patients up front Have differing strategies based on Days in A/R

Collections : All Payers
Collection Snafus ABN given to patient; no collection because patient did not understand what it meant Patients believe insurance covers everything Medicare Advantage patients have big out-of-pocket and did not this would happen when they signed up Balance between aggressive collections and patient relations. This will gain in importance as patient opinions will really count Cancer patients have collections from many sources and may play on physicians’ sympathies

Collection Rates for Common Oncology Services from Charges
Type of Service Collection Rate E/M 41.03% Imaging 19.83% Radiation 27.55% Drugs 39.35% ALL SERVICES 37.88%

Collection Percentage from Allowables by Service 2016
Type of Service Collection Rate E/M 79.90% Imaging 60.96% Radiation 90.80% Drugs 87.41% ALL SERVICES 86.13%

Best Collection Rates by Insurance Company in 2016 (U. S
Best Collection Rates by Insurance Company in 2016 (U.S.)—Injectable Drugs

Denials & Appeals Cancer Service 2016

Denial Rates by Service 2016
Type of Service Denial Rates E/M 5.06% Imaging 9.67% Radiation 8.03% Drugs 7.84% ALL SERVICES Good work, everybody!!!!

Highest Denial Rate for Tracked Drugs In focalPoint (2016)

Top Geographic Areas With Denials 2016 (Drugs Only)

Denials by State—All Other Services 2016

Top Denials for 2016: E/M Services

Top Denials for 2016: Imaging

Denials for 2016: Radiation Oncology

Top Denials for 2016—Drugs

Top 2016 Denials for All Services

Top Reasons for Denials 2016
Denial Code 97—This payment is included in the payment for another service Denial Code 16—Claim lacks information for adjudication Denial Code 50- Claim lacks medical necessity Denial Code 96—Non-covered charges Denial Code 197—Precertification/ pre-authorization missing

Denial Code 97—This Benefit Is Included in The Payment for Another Service (14.7%)
Previously paid claim now seen as a duplicate claim (RARC N111) Bundled claim either due to capitation, episode of care, or not allowed by the payer to be separately payable like fluids and mixing drugs (RARC M15) Consult our contractual agreement, e.g. not meeting payer policies (RARC N381) Basic lessons: Do not track claims by re-billing; touch each claim every 30 days Understand billing parameters of every contract---what is included and what is not Do not routinely bill items that are bundled—fluids, needles, sysringes, etc.

Denial Code 16—Missing Information (12.03%)
Most frequent denial code for all items and services outside of Oncology Mostly clerical errors in billing But, some can be avoided knowing the reasons: Missing or incorrect NDC number (M119) Missing or invalid dose of drug, name of drug Missing documentation/orders/notes/summary/report/chart (RARC N29) Overall, this is a delay tactic, but if a documentation request is made, some MACs will deny the claim permanently if info is not received in 45 days Tips NDC must be 5-4-2 Ensure you provide the right documentation at prior auth

Denial Code 50—Not Medically Necessary (9.14%)
Most people think this is due to off-label use; but, do not ignore vague coding or incorrect coding If it is truly off-label, appeal using Compendia support that meets state requirements Evidence-based guidelines used for the patient All previously failed therapies All therapies ruled out Some drug companies can help you with literature

ICD-10-CM Codes Frequently Billed for Drugs 2016

ICD-10 Codes Most Frequently Denied Drugs in 2016 (> 15 claims)

Diagnosis Coding 2016: Denials for 2016

Denial Code 96—Non-Covered Charges (6.93%)
Many people mistake this denial code to mean that the patient does not have coverage at all or that the drug billed is not covered. What this really means is RARC Codes N381 & N130—Consult our contractual agreement for payment restrictions and consult plan benefits about payment restrictions RARC Code N30—Patient ineligible for this service RARC Code N362—Units or days exceeds our limits Basic message: Know the limits of plan coverage up front. This can mean Billing deadlines Charge parameters if it is charge-based payment Patient eligibility for services above preventative in early employment Check if there are MUEs or other unit limits on drugs

Denial Code 197—Pre-Authorization Missing (5.4%)
We are seeing this everywhere—every non-generic drug claim should have a PA Practices and clinics have told us that this is happening because The plan tells the insurance verifier that no authorization necessary; The clinic or practice “has never needed one before” Lack of coordination between the prior authorization body and the insurance plan Poor coordination between those obtaining authorization and billing Some payers have more than one vendor doing PA

Denials/Appeals Who What Best Practices Offices-Usually “Back Office”
Hospitals-Variable What Discover denied claims that need to be addressed clinically Find zero paid claims and address them by phone, by cancelling claim and re-billing Best Practices Know the difference between delay tactics and denials Have a team approach to clinical denials (Denial codes 50/55/56, plus others that describe payer policies)

From NGS Medicare

Medicare Appeals Strategies: Overview
Rebuttal and Discussion Period Redetermination Appeal deadline: 120 days (30 days to avoid recoupment) Reconsideration Appeal deadline: 180 days (60 days to avoid recoupment) Administrative Law Judge Hearing Appeal deadline: 60 days CMS will recoup the alleged overpayment during this and following stages of appeal Medicare Appeals Council (MAC) Federal District Court

CALCULATING TIME FRAMES
Time frames are generally calculated from date of receipt of notice 5 days added to notice date Time frames sometimes extended for good cause, examples include: Serious illness Death in family Records destroyed by fire/flood, etc Did not receive notice Wrong information from contractor Sent request in good faith but it did not arrive

MEDICARE ADVANTAGE APPEALS
“Organization determination” is initial determination regarding basic and optional benefits Can be provided before or after services received Issued within 14 days May request expedited organization determination if delay could jeopardize life/health or ability to regain maximum function. Plan must treat as expedited if requested by doctor Issued within 72 hours

MEDICARE ADVANTAGE (MA)
Request reconsideration w/i 60 days of notice of the organization determination. Reconsideration decision issued within 30 days for standard reconsideration. 72 hours for expedited reconsideration. Unfavorable reconsiderations automatically referred to independent review entity (IRE). Time frame for decision set by contract, not regulation Unfavorable IRE decisions may be appealed to ALJ to MAC to Federal Court

MEDICARE ADVANTAGE (MA)
Fast-Track Appeals to Independent Review Entity (IRE) before services end for Terminations of home health, SNF, CORF Two-day advance notice Request review by noon of day after receive notice IRE issues decision by noon of day after day it receives appeal request 60 days to request reconsideration by IRE 14 days for IRE to act

PART D APPEALS PROCESS- OVERVIEW
Each drug plan must have an appeals process Including process for expedited requests A coverage determination is first step to get into the appeals process Issued by the drug plan An “exception” is a type of coverage determination Next steps include Redetermination by the drug plan Reconsideration by the independent review entity (IRE) Administrative law judge (ALJ) hearing Medicare Appeals Council (MAC) review Federal court Intro – Topic, On-going Project Presenters – VG & PN Sr Policy Attys / DC JAS / CT Much info NOT all slides A FEW edits since sent to MS Q & A at end to be efficient with time so keep notes of Qs Not: Until then you are on MUTE – We can’t hear you

PART D APPEALS PROCESS – COVERAGE DETERMINATION
A coverage determination may be requested by A beneficiary A beneficiary’s appointed representative Prescribing physician Drug plan must issue coverage determination as expeditiously as enrollee’s health requires, but no later than 72 hours standard request Including when beneficiary already paid for drug 24 hours if expedited- standard time frame jeopardize life/health of beneficiary or ability to regain maximum function.

EXCEPTIONS: A SUBSET OF COVERAGE DETERMINATION
An exception is a type of coverage determination and gets enrollee into the appeals process Beneficiaries may request an exception To cover non-formulary drugs To waive utilization management requirements To reduce cost sharing for formulary drug No exception for specialty drugs or to reduce costs to tier for generic drugs A doctor must submit a statement in support of the exception

PART D APPEALS - COVERAGE DETERMINATIONS ARE NOT AUTOMATIC
A statement by the pharmacy (not by the Plan) that the Plan will not cover a requested drug is not a coverage determination Enrollee who wants to appeal must contact drug plan to get a coverage determination Drug plan must arrange with network pharmacies To post generic notice telling enrollees to contact plan if they disagree with information provided by pharmacist or To distribute generic notice

PART D APPEALS PROCESS NEXT STEPS
If a coverage determination is unfavorable: Redetermination by the drug plan. Beneficiary has 60 days to file written request (plan may accept oral requests). Plan must act within 7 days - standard Plan must act within 72 hrs.- expedited Then, Reconsideration by IRE Beneficiary has 60 days to file written request IRE must act w/i 7 days standard, 72 hrs. expedited ALJ hearing MAC review Federal court

PART D GRIEVANCE PROCESS
Each drug plan must have a separate grievance process to address issues that are not appeals May be filed orally /in writing w/i 60 days Plans must resolve grievances w/i 30 days generally w/i 24 hrs if arise from decision not to expedite coverage determination or redetermination

Writing A Good Appeal Pre-Appeal
Know your State cancer laws: off-label and clinical trials Know your state insurance laws Prior authorization Appeal rights Medicaid Know your Medicare laws Understand major payer contracts Drug carve outs Appeal deadlines Legal rights Involve the clinician and have them sign the appeal

Successful Appeals Strategies:
What’s Your Argument? Clinically-based arguments: Medical necessity of the services provided Appropriateness of the treatment based on clinical history or community standard Scientific support for treatment; compendia if possible Legally-based arguments: Is the denial legal based on the coverage or contractual parameters surrounding the claim? Summarize submitted medical records and documentation to fit your argument in terms of the parameters chosen or just send proof you complied Have a Medicare or healthcare lawyer review as appropriate Use of past Medicare Appeals Council cases ecisions.html

A Fantastic Resource

Solutions: Front Desk/ Intake
Front Desk/ Financial Counseling Technology Eligibility/verification products On-line eligibility verification AS LONG AS it’s thorough Insurance company websites and links Contract book—describes all plans, prior auth, referral policies, excluded providers Access to denials consistent with poor intake Establish standardized registration polices, procedures, processes and performance levels, particularly for registration data quality Ensure that registration staff is thoroughly trained Insurance plans and requirements prior to treatment Plan requirements, e.g., referrals, authorizations Importance of correct demographics

Solutions: Billing Charge Posting/Billing
Have standard billing instructions for every large payer Computerized coding tools, particularly ICD-10-CM Updated charge capture/Superbills Claims editors Claims “scrubbers” Online access to Medicare policies for all providers Online access to policies and procedures for miscellaneous J-codes

Solutions: Prevent Audits
Make sure that you are using evidence-based guidelines for all regimens in the practice Avoid duplicate claims Stay away from “chair visits” Conform to profiles for E/M and Radiation Do not track waste for multi-dose vials (“MDVs”), e.g. bendamustine and trastuzumab Audit every ’big ticket’ claim (set a benchmark) before transmitting to the payer

E/M Profiling for Hem-Onc Practices 2016

Radiation Delivery Profiling for Hem-Onc Practices

What I Tell Practices Benchmark yourself against local and national statistics Remember that the more work done up front, the more will pay off in the long run Advanced Financial Counseling is a real key to success… Co-pay cards and Foundations are key to your solvency—track your revenue Every person in the Revenue Cycle should have incentives—pay, PTO, pizza, etc. Invest in systems to track, work and report denials, e.g. 835 data and benchmarking Assign responsibility for denials and reward people for improvements in denial rates in terms of Correct demographics Reduction of prior auth denials (197 &15) No expired claim submissions No wrong primary payers Minimal requests for more info Measure improvement on an ongoing basis: don’t start and stop! Participate in the struggle with COA!

Appendices

Northeast—Top Thirty Payers Injectable Drugs Only

Northeast—Worst Days To Pay Injectable Drugs (2016)

Southeast—Top Thirty Payers Injectable Drugs Only

Southeast—Worst Days To Pay Injectable Drugs (2016)

Heartland—Top Thirty Payers Injectable Drugs Only

Heartland—Worst Days To Pay Injectable Drugs (2016)

The West—Top Thirty Payers Injectable Drugs Only

The West—Worst Days To Pay Injectable Drugs (2016)

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Revenue Cycle State of the State

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