Intersect Healthcare

Protecting Provider Revenue

CMS Audits Highlight MAO Performance Problems Related to Denials

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By R. Kendall Smith, Jr., MD, SFHM

A report released by the HHS Office of Inspector General (OIG) in September 2018 found that Medicare Advantage Organizations (MAOs) overturned a jaw-dropping 75 percent of their own denials from 2014 to 2016. Even more startling was that independent reviewers at higher levels within the appeals system reversed originally denied claims, finding in favor of beneficiaries and providers.

Furthermore, 45 percent of contracts were cited by CMS for sending denial letters with incomplete or misleading information, which may have hindered providers’ or beneficiaries’ chances of prevailing with an appeal. What appears of immense concern in this report was the comment that CMS continues “to see the same types of actions in its audits of different MAOs every year.” More telling was that 76 MAO contracts overturned more than 90 percent of their own denials upon appeal, including seven contracts that overturned more than 98 percent.”

Given these astounding overturn numbers, one has to wonder why beneficiaries and providers appealed only 1 percent of denials to the first level of appeal—reconsideration by a Quality Improvement Organization or their MAO. The remaining 99 percent of denials go unchallenged despite an almost four out of five chance of prevailing on appeal.

In the words of Bob Marley: “Get Up, Stand Up, don’t give up the fight.” Stop letting money flow down the drain.

Learn how your organization can save time and resources amidst increasing volumes of Medicare, Medicaid, and commercial payer denials.

Appealing Medicare Advantage Denials For Patients Gives Hospitals More Leverage

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Reprinted with permission by the Report on Medicare Compliance

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.”

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Why You Should Include Payer Payment Guidelines in Appeal Templates

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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.

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The Use of Evidence Based Medicine in Appeal Letter Templates

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Insurance company denials of payment are rarely issued in a random and infrequent manner. Most denials for services rendered are grouped around specific issues on payment policies, as defined by the insurance carrier. As an appeal writer, it only makes sense to develop appeal letter templates that will hold the supporting arguments for payment and can be used for each of the various issues.

Using an appeal letter template allows for increased efficiency in performing appeal work. The research of each insurance carrier’s payment policy is completed once at the time the template is developed. By tailoring the appeal argument to each specific issue that the payer has identified as the reason for the denial, it eliminates the need to write each appeal from scratch.

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Leveraging Limitation on Liability to Win Appeals

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Limitation on Liability is a very common phrase to appeal writers, specifically when dealing with government denials. It’s a crucial argument that is vital to a winning appeal argument. Have you ever stopped to think about what that phrase means? Have you ever dug deep into government regulations to really understand Limitation on Liability and how it should be used to support your winning argument?

Where it Comes From

Limitation on Liability comes from the Social Security Act § SEC. 1879. [42 U.S.C. 1395pp] to be exact. http://www.ssa.gov/OP_Home/ssact/title18/1879.htm. Remember, all things Medicare and Medicaid were born through the Social Security Act, and are formed through the Code of Federal Regulations, and interpreted by CMS. When you read the Limitation on Liability of Beneficiary Where Medicare Claims Are Disallowed, which is the full title, you see the phrase “provider of services … did not know, and could not reasonably have been expected to know, that payment would not be made for such items or services under such part A or part B,” multiple times. This is the essence of the Limitation on Liability portion of the Social Security Act as it relates to denial of payment for services under Medicare. [Read more…]

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