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Revenue Cycle State of the State:

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Presentation on theme: "Revenue Cycle State of the State:"— Presentation transcript:

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

2 Disclaimer and Introductions
Nothing in this presentation is to promote off-label use of any particular product or service. No drug manufacturer sponsored this program or promoted use of products for this webinar. Thus brand names are used where applicable. Benchmarks are just suggestive. Your payer mix or patient acuity may significantly impact your numbers and they may differ from what is seen herein. This seminar is suggestive and is not consulting or legal advice.

3 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???

4 Our Data Source FocalPoint 2016 Data Represents 165+ Cancer Centers, 725 sites of service, 478 payers and 2,300 Hematologists and Oncologists Metrics Through August 2017 Total for Drugs New Jersey for Drugs Payer responses to claims (includes submission and resubmissions) 7,011,350 331,316 Distinct patients 319,711 15,646 Distinct claims 2,256, 924 108,087

5 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”)

6 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

7 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 Resubmission Rate = Payer responses divided by number of claims 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

8 Revenue Cycle The Who, Snafus, and Best Practices

9

10 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…

11 Revenue Cycle: Hospitals

12 Payer Mix focalPoint Database 8/1/2016 to 7/31/2017—All of U.S.

13 Payer Mix by Patients—New Jersey

14 Part B Accounts Receivable: Total Across U.S. (2016)
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%

15 Part B: Account Aging for Injectable Drugs 2016-2017 (Insurance Only-Top 25 Payers)

16 Part B: Account Aging for Injectable Drugs New Jersey 2016-2017 (Insurance Only-Top 25 Payers)

17 “Old” Drug Claims (≥ 180 days) in New Jersey 2017 YTD

18 “Old” Drug Claims (≥ 120-180 days) in NJ 2017 YTD

19 “Old” Drug Claims (≥ 120 Days) in NJ 2017 YTD—MAJOR REASONS

20 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

21 Revenue Cycle Metrics Measures the cash momentum by accounting for shifts in revenue Not a good relative measure against other organizations due to contractual differences Cash Factor (Cash/3 month Average Daily Revenue) # of accounts collected per day, week, month by $ size, age, unit, and individual Collections 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 Write-Off % (ABCs)

22 Days to File By Service (With Outliers)- Rolling 2016-2017
Service Type Days to File E/M 16.57 Imaging 15.93 Radiation 21.38 Drugs 16.00 ALL SERVICES 14.39

23 Days to File for Injectable Drugs Only 2016-2017—U.S.

24 Top 25 Payers DTF Without Outliers for Drugs-New Jersey In Florida 2016-2017

25 Top Days To File With Outliers for Drugs—New Jersey In Florida 2016-2017

26 Days To Pay With Outliers 2016 by Service
Type of Service Days To Pay E/M 18 days Imaging 44 days Radiation 27 days Drugs 38 days ALL SERVICES 22 days

27 Top Worst Insurance Companies by Days To Pay-IV Drugs (Without Outliers) New Jersey (≥ 5 claims) over 30 days

28 Top 25 Worst Insurance N.J. Companies by Days To Pay-IV Drugs With Outliers (N ≥ 5 claims)

29 Top Ten Injectable Drugs DTP for 2016-2017 All U.S.
Drug Name Claims DTP Synribo 12 154 Temozolomide 49 78 Melphalan 5 61 Zevalin 17 55 Sylvant 105 51 Blincyto 21 45 Yondelis 312 44 Portrazza 487 41 Lartruvo 718 40 Marqibo 39

30 Top Ten Injectable Drugs DTP for 2016-2017 In New Jersey
Drug Name Claims DTP Portrazza 33 57 Adcetris 32 44 Aranesp 18 Treanda Liquid 10 63 Yervoy 43 40 Doxil 187 35 Xofigo 16 34 Cyramza 287 Darzelex 302 Entyvio 104 Top Ten Injectable Drugs DTP for In New Jersey

31 Re-Submission Rate 2017: U.S. and New Jersey
U.S. = 1.62 times

32 Revenue Cycle Step-by-Step
How to PREVENT Denials Revenue Cycle Step-by-Step

33 Pre-Visit: Medicare Who “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

34

35 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

36 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

37 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

38 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 Pre-Visit: Private Insurance

39 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.

40 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

41 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

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

43 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 Medical Records/Coding

44 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, Laterality 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

45 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 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

46 Billing Who “Back Office” What 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

47 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

48 Collections Who “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

49 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

50 Collection Rates for Common Oncology Services from Charges
Type of Service Collection Rate E/M 40.65% Imaging 20.32% Radiation 27.67% Drugs 39.14% ALL SERVICES 37.68%

51 Denials & Appeals Cancer Services 2016

52 Denial Rates by Service Rolling 2016-2017
Type of Service Denial Rates E/M 9.78% Imaging 18.34% Radiation 12.27% Drugs 7.89% ALL SERVICES 18.23%

53 Highest Denial Rate for Tracked Drugs In focalPoint (2016-2017)

54 Geographic Areas With Denials 2017 to Date (Drugs Only)

55 Denials by State—All Other Services 2016-2017 Rolling
Type state Denials Responses DENIAL RATE Rad Onc PR 80 258 31% PA 1547 6472 24% MS 996 4610 22% KY 1497 7214 21% CA 18450 92349 20% UT 1568 7937 ID 2503 12893 19% TX 5251 27166 IL 10949 57273 LA 14647 77142 IA 1773 9619 18% FL 28196 153540 NM 2333 12717 AZ 2688 15659 17% OK 6724 39201 WA 11177 67885 16% GA 13364 84394 IN 3973 25156 WY 2929 18816 NY 4065 26193 NC 4773 32315 15% AR 8885 64818 14% AL 2194 16201 SC 3467 26589 13% MD 18102 TN 7072 58945 12% MA 240 2070 RI 1046 10590 10% ND 68 704 NJ 340 3648 9% WI 1265 16170 8% NE 761 12989 6%

56 Top Denials for 2016-2017: E/M Services

57 Top Denials for 2016-2017: Imaging

58 Denials for 2016-2017: Radiation Oncology

59 Top Denials for 2017—Drugs

60 Top 2016 -2017 Denials for All Services

61 Top Denials for 2016—2017 for NJ Drugs

62 All Payers With Denials for 2016—2017 for NJ Drugs (>1)

63 Top Drugs for Denials in 2016—2017 for New Jersey

64 New Jersey Denial By Tumor Type Over Time

65 Common Reasons for New Jersey Drug Denials 2016-2017
Denial Code 16 (NY)—Claim lacks information for adjudication Denial Code 97—This payment is included in the payment for another service Denial Code 50- Claim lacks medical necessity Denial Code 22—This claim is covered by another contractor Denial Code 204—Claim not covered under the patient’s current benefit plan

66 Denial Code 16: Remarks 2016-2017 In New Jersey

67 Denial Code 16—Missing Information
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 Wrong plan information 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 Check your diagnosis coding Make sure your plan information is right

68 Denial Code 97—This Benefit Is Included in The Payment for Another Service (NJ)

69 Denial Code 50—Not Medically Necessary
Most people think this is due to off-label use; but, do not ignore vague coding or incorrect coding, particularly for certain insurance companies 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

70 ICD-10-CM Codes Frequently Billed for Drugs 2017

71 ICD-10 Codes Most Frequently Denied Drugs in 2017 (> 15 claims)

72 ICD-10 Codes Most Frequently Denied Drugs in New Jersey 2017 (> 15 claims)

73 Q7: What part of Revenue Cycle Management for ALL ITEMS and SERVICES do you find most challenging? Use a scale of zero to five with 5 being most challenging and zero being no problem Responses

74 Q10: Why are so many claims denied for missing or lack of prior authorization? Please select all that apply... Answered: Skipped: 324

75 Q10: Why are so many claims denied for missing or lack of prior authorization? Please select all that apply... Answered: Skipped: 324

76 Denial Code 22—Not Billed To This Contractor
Front desk should make sure that information on primary and secondary insurance is correct All insurances must be verified as primary or secondary Does the patient have Medicare that might be billed to someone else? Mesothelioma? Check old records

77 Denial Code 204—Not Covered Under The Patient’s Benefit Plan
Can this possibly be WHITE BAGGING? Did you bill pharmacy plan by mistake? Is this a bad plan that covers little?

78 Denials/Appeals Who 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) Denials/Appeals

79 From NGS Medicare

80 Medicare Appeals Strategies: Overview ($ Cut-offs Vary By Year)
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

81 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 CALCULATING TIME FRAMES

82 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 APPEALS

83 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

84 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 MEDICARE ADVANTAGE (MA)

85 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

86 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. PART D APPEALS PROCESS – COVERAGE DETERMINATION

87 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

88 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

89 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

90 PART D GRIEVANCE PROCESS
Each drug plan must have a separate grievance process to address issues that are not appeals 01 May be filed orally /in writing w/i 60 days 02 Plans must resolve grievances 03 PART D GRIEVANCE PROCESS

91 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 Writing A Good Appeal

92 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 ons.html

93 A Fantastic Resource

94 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: Front Desk/ Intake

95 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: Billing

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

97 Hem-Onc E/M Profiling from AAPC Website (2015)
New Patient Visits 2015 % 99201 0.1% 99202 1.0% 99203 9.1% 99204 36.2% 99205 53.8% Established Patient Visits 2015 % 99211 2.3% 99212 2.6% 99213 32.0% 99214 51.9% 99215 11.2%

98 Hem-Onc E/M Profiling for New Jersey (2016)
New Patient Visits 2016 % 99201 0.0% 99202 0.5% 99203 8.0% 99204 41.0% 99205 50.4% Established Patient Visits 2016 % 99211 1.9% 99212 4.9% 99213 39.1% 99214 46.1% 99215 8.0%

99 Med Onc E/M Profiling for New Jersey (2016)
New Patient Visits 2016 % 99201 0.1% 99202 0.9% 99203 8.1% 99204 47.4% 99205 43.5% Established Patient Visits 2016 % 99211 1.0% 99212 6.2% 99213 46.4% 99214 41.8% 99215 4.6%

100 Rad Onc E/M Profiling for New Jersey (2016)
New Patient Visits 2016 % 99201 0.2% 99202 0.4% 99203 7.2% 99204 39.4% 99205 52.9% Established Patient Visits 2016 % 99211 0.6% 99212 9.1% 99213 40.6% 99214 40.2% 99215 9.5%

101 AAPC Web Site https://www.aapc.com/resources/em_utilization.aspx

102 E/M Profiling for Hem-Onc Practices 2016

103 Radiation Delivery Profiling for Hem-Onc Practices 2016

104 What I Tell Practices Watch for the next iteration of Trumpcare, if there is one 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 Correct insurance verification No vague diagnoses Minimal requests for more info Measure improvement on an ongoing basis: don’t start and stop! Participate in the struggle with NJSOM!


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