Intersect Healthcare invites all healthcare compliance professionals to meet with their team April 15-18, 2018, at booth 419 to learn how their VERACITY software suite offers the most comprehensive solution for managing audits, risks, denials, and appeals.
Permission to reproduce granted by RACmonitor
By Denise Wilson, RN, MS, RRT
EDITOR’S NOTE: With Hurricane Irma expected to impact Miami-County today, this story, updated from a news alert posted last week on the ICD10monitor website, offers lessons learned for hospitals and caregivers in the path of Irma.
Our thoughts continue to go out this week to the people of Texas, especially the first responders and caregivers and all who have been impacted by Hurricane Harvey. Harvey made landfall in Texas on August 25th as the strongest hurricane to hit the U.S. in more than a decade. Since Harvey’s landfall, southeast Texas has experienced catastrophic flooding, devastation of homes and loss of lives.
Practical steps to reduce insurance denials and steadily improve the bottom line
By Kendall Smith, MD | Chief Physician Advisor to the Intersect Healthcare Leadership Team
I was writing an appeal for a hospital system the other day to a large insurer. It was one of many similar appeals related to the same medication and the same procedure I’d written many other times over the previous few months. It then occurred to me that, absent some feedback to the physicians involved, likely, I’d be addressing any number of similar denials again a year down the road.
Fed up with claim denials for inpatient admissions by Medicare Advantage (MA) plans months after they were approved, Self Regional Healthcare in Greenwood, S.C., complained to the CMS regional office in Atlanta.
“We started sending information to CMS saying that if the Medicare Advantage plans do concurrent review and authorize inpatient care, we have every right to expect payment,” said Roy Baker, M.D., medical director of case management. Otherwise, the hospital should have the right to hold the beneficiary liable for the hospital stay. That had an impact. “CMS cares about beneficiaries. They took that to heart and [went to] the Medicare Advantage plan,” Baker said at a March 8 webinar sponsored by Intersect Healthcare and AppealMasters. “In 24 hours, a group of denials was overturned in one fell swoop. It made my CFO happy.”
Including payer payment guidelines in your appeal letter templates can increase the efficiency and effectiveness of your appeal writing. Most payers develop and publish very specific payment guidelines for medical and surgical procedures. This ensures payment is made only for services that are medically necessary to effectively treat a person in a medically effective but also fiscally responsible (read least expensive) way. CMS publishes these payment guidelines as National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). Commercial payers often times publish their payment guidelines as Clinical Policy Bulletins (CPB), Medical Policies, or other similar titles. It’s generally easy to find these guidelines on the Internet. CMS has a Medicare Coverage Database (MCD) that can be accessed at http://www.cms.gov/medicare-coverage-database/. You can find both NCDs and LCDs there. Most commercial payers publish their CPBs in the Provider area of their public websites. You must also consider if your provider organization is contracted with the payer and whether there are additional coverage policies that may apply.