The Role of Patient Access in Denial Prevention and

InterventionPresented by: Sarah Mendiola, Esq.

Associate Attorney Fotheringill & Wade, LLC

Discussion Objectives

Patient Access Issues and Goals.

The Role of Patient Access in the prevention of Lack of Authorization denials.

Best Practice concepts for denial prevention.

What to do if a claim is denied.

Patient Access Goals

Increase rate of clean claims billed;

Reduce denials and administrative burden of rebilling claims/appeals;

Increase collection of patient responsibility; and

Identify services that might result in zero payment prior to being rendered.

Patient Access Challenges

Cause Effect Accurate patient data not

captured prior to the visit. Staff members uncomfortable

communicating patient financial obligation.

Processes are manual, rather than automated.

Inconsistent policies and procedures for registration.

Likelihood of clean claim decreases.

Reduced opportunity to collect full amount owed by patient.

Longer patient wait times, decreased patient satisfaction.

Missed revenue opportunities, team not operating at best practice level.

Patient Access Solutions

Leadership and employee education on the importance of accurate data collection and insurer requirements.

Consistent processes across all patient access areas for insurance verification, determination of patient financial responsibilities and point of service collections

Push for insurers to standardize practices and make requirements clear/easily accessible.

Robust and automated reporting to facilitate identification of opportunities for improvement.

Know how to spot denials so that opportunities for appeal are not lost!

Administrative Denials – Some Top Reasons The claim was filed Late The Insurance Company Lost the

Claim, and then the Claim Expired Lack of Preauthorization/

Authorization The Patient Didn’t acquire a

Referral from a Physician You Ran Out of Authorized Sessions The Authorization Expired The Patient Changed His or Her

Insurance Plan The Patients' Out-of-network

Benefits Differ from In-network Benefits

The Service was Already Rendered The Patient has an Out-of-State

Insurance Plan The Patient Lost His or Her

Insurance Coverage The Patient was Late to pay their

COBRA Claim sent to the Wrong Managing

Company The Provider doesn’t participate

with the Insurance Company Services Were Rendered at the

Wrong Location

According to a 2012 study completed by the AMA, “The current prior authorization process is extremely burdensome.”

The AMA’s report had the following findings: Hassle factors related to the prior authorization requirements need to

be eliminated. Preference for an automated prior authorization process. Vague prior authorization requirements. Long wait times with prior authorization requests. Difficulty obtaining approval of prior authorization requests. 20 percent of first-time prior authorization requests are rejected by

the payers. Physician practices need to appeal 80 percent of payer rejections of

first-time prior authorization requests.

Electronic Prior Authorization Practices According to the AMA, handling your prior authorizations electronically can:

Speed up health insurer response. Minimize time and resources devoted to manual processes, such as

waiting on hold and compiling faxes to payers. Free up time for revenue-enhancing functions such as ensuring

correct payment. Reduce transaction costs by over 80%. Provide a paper trail to appeal claims that are subsequently denied.

Verify authorization prior to performing services! Is authorization needed for this particular service under this patient’s

plan? Check provider website/portal and/or call to verify.

If authorization was obtained: Does it cover this particular service? Is it for this date? Is it still valid?

Has it been used already?

Lack of Authorization denials can come in many different forms!Auth Obtained/Erroneously denied

Scheduled Admit/Hospital failed to contact payer/obtain auth

Additional days requested/auth approved for lower level of care

Additional days requested/auth refused

Additional days not requested/stay exceeded auth

Auth not obtained but not required

Example of a Denial #1-Hidden Denial?

What does this really mean?

“Claim/service denied because the procedure/treatment is deemed experimental/investigational by the payer”

The service must have been experimental, right?

This patient was admitted through the ED and had an appendectomy.

Authorization was requested at the time of admission and was granted.

The authorization was later denied, after clinical information was submitted. The plan indicated that the patient could have been treated at a lower level of care.

This was not an experimental service!

Best Practice Denial ManagementMaximize Opportunities with Appeal Team

Intervention/Appeal Track Purpose:

To prevent retraction or obtain full payment

Methodology:To pursue all appeal levels until payment received or appeal and dispute resolution procedure exhausted.

Prevention Track Purpose:

To prevent future denials & ensure compliance.

Methodology:Provide appropriate feedback to Hospital staff

Track all denials by Physician and Coder

Educate & respond according to data

Monitor & Measure Response

If I Knew Then What I Know Now… The information that is obtained during the admitting

process is crucial to prevent and fight denials!

Almost all technical denials can be challenged: Facts State and federal laws Contract provisions

Registration and Admitting staff should have access to key contract provisions and laws: Prevention of denials Obtain critical facts

Insurance Verification Process Just asking the right questions can prevent denials.

Verify eligibility and plan type and elicit information that is not routinely provided:

Specific policy exclusions Pre-existing conditions

Opportunity to correct potential benefit problems: Early registration Lapses in coverage during admission/patient involvement

Documentation is the key to effectively preventing and fighting

denials.

Commercial vs. MedicareLess work on the front end?

Still need to verify benefits! Does the patient have Part A and/or Part B benefits? Confirm the patient has not enrolled in Part C. Hospice election?

No authorization needed for Medicare UNLESS Medicare Advantage Plan. Requirements are plan specific. Contracted vs. Non-Contracted

What documentation will be needed for this service? If the patient is being pre-registered, can we tell them what to bring with them?

Example of a Denial #2-Hidden denial?What does this mean?

Remit Date 11/14/13MA02Claim Level CO A1-Claim denied charges.MA02 Alert: If you do not agree with this determination, you have the right to appeal.

Example of a Denial #2Could this have been prevented?

The patient was admitted for a scheduled, elective Total Knee Replacement.

DRG 470 has consistently been targeted for pre-payment review.

Medicare requires that certain documentation be present in the record to show that the procedure was medically necessary.

If the pre-operative documentation to show that the surgery was reasonable and necessary is not present, the entire hospital stay may be denied.

MLN Matters Number SE1236-Documenting Medical Necessity for Major Joint Replacement (Hip and Knee).

Example of a Denial #2How could this have been

prevented? Best practices would involve coordination between the orthopedic surgeon’s office and the provider so that the documentation is provided at the time of registration. Checklist of documentation requirements. Packet must be submitted at the time of registration.

Notify the patient during pre-registration that they can/should bring any and all documentation related to the procedure when they arrive. Major joint surgery is often the last resort and the patient may

have been receiving various treatments over an extended period of time.

Example of a Denial #3Could this denial have been prevented?

“These are non-covered services because this is not deemed a “medical necessity by the payer.”

Example of a Denial #3Could this denial have been prevented?

CPT Code 93880: Duplex scan of extracranial arteries; complete bilateral study.

Novitas Solutions LCD L27504 explains the coverage criteria for Non-Invasive Cerebrovascular Arterial Studies.

The patient was pre-registered for the outpatient diagnostic study. Pre-procedure documentation from the referring physician to explain

the rationale for the test could have aided in ensuring that a clean claim was billed and preventing the denial.

Example of a Denial #4Could this denial have been prevented?

“Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.”

Example of a Denial #4Could this denial have been prevented?

CPT Code 23472: Total Shoulder Arthroplasty This was an Inpatient-Only Procedure billed on an outpatient claim.

This was an elective, scheduled procedure. The patient was pre-registered for the surgery. The facility could have an electronic “hard stop” instituted for certain

surgical codes that are on the inpatient-only list. This would trigger the patient access department to register the patient as an inpatient.

How can we argue this denial?

What if you think you’ve done everything right?

And the claim is still denied?

Appeals should include: Documentation of telephone conversations:

Name, phone #, and department of the person providing benefits and/or authorization.

Whether the entire admission was authorized and any concurrent review (and proof) that it was provided.

Copy of written authorization.

Applicable contract terms.

Applicable state law.

Important Contract Provisions Authorization/Notification requirements? Are they explicitly in the

contract, or is the provider manual controlling? Under what circumstances is authorization required? Timeframes? Authorization number v. tracking number? Referrals? Updates to provider administrative guidelines?

Concurrent review requirements? How often? When does it start?

Verification of benefits requirements?

Real Contract Provisions!“In the event that the lack of authorization can reasonably be shown to have resulted from an action or inaction by Hospital, and Insurer determines the services to be Medically Necessary, than Insurer shall reimburse Hospital for all Medically Necessary Covered Services rendered to the Member.”

“Notwithstanding anything to the contrary herein, Insurer shall not deny or reduce payment for any Medically Necessary Covered Services based on Hospital’s failure to comply with any administrative or notification requirements as set forth in this Agreement and/or the Provider Manual insofar as such services would have been authorized as Medically Necessary if the notification had been provided in the appropriate time.”

There are federal and state laws on the following denial management topics: Authorization

Modification of authorization, delivery/newborn, emergency services

Claims submission Minimum time frames

Prompt payment Definition of clean claim,

payment time frames, interest penalty

Misverification of benefits Internal/External Appeals

• Retroactive denials/Retractions• Notice prejudice• Lien laws

• Workers compensation, Third Party Liability

• Pre-existing conditions• Emergency Services

• State law definition, EMTALA • Continuation of Benefits• ERISA• Coordination of benefits• Automatic newborn coverage• Experimental treatment

Maryland Insurance CodeTitle 15-Health Insurance

Just a few Maryland Laws regarding health insurance issues that may come in handy:

Subtitle 4. Eligibility for Coverage; Continuation and Conversion of Policies

Subtitle 6. Required Reimbursement of Institutions. Subtitle 10. Claims and Utilization Review.

§ 15-1005-Prompt payment of claims. § 15-1006-Notice of reason for claim denial.

Subtitle 10A. Complaint Process for Adverse Decisions or Grievances

Maryland Insurance Code and Prior Authorization!§ 15-1009 (b) Reimbursement for preauthorized care - If a health care service for a patient has been preauthorized or approved by a carrier or the carrier's private review agent, the carrier may not deny reimbursement to a health care provider for the preauthorized or approved service delivered to that patient unless:

(1) the information submitted to the carrier regarding the service to be delivered to the patient was fraudulent or intentionally misrepresentative;

(2) critical information requested by the carrier regarding the service to be delivered to the patient was omitted such that the carrier's determination would have been different had it known the critical information;

(3) a planned course of treatment for the patient that was approved by the carrier was not substantially followed by the health care provider; or

(4) on the date the preauthorized or approved service was delivered:

(i) the patient was not covered by the carrier;

(ii) the carrier maintained an automated eligibility verification system that was available to the contracting provider by telephone or via the Internet; and

(iii) according to the verification system, the patient was not covered by the carrier.

Legal theories that may also be useful: Misrepresentation

Detrimental reliance

“But for” or without the affirmative action on the part of the insurer, the provider would not have provided

the medically necessary services.

Example 1

“Our Hospital” rendered medically necessary services to John Doe from 7/1/13 – 8/22/13. Authorization was obtained. On 9/30/13, the hospital timely submitted a claim with total charges of $150,687.20 to It’s all about You Insurance.

On 11/28/13, It’s all about You Insurance denied the claim on the basis that John Doe was not eligible for benefits during the date of service.

What is our best argument?

Benefits/eligibility was verified. Name, phone#, and department of the

representative that verified benefits, or a printout of the benefits from the plan’s website.

The benefits that were quoted. The effective date of the patient’s policy. Any policy limitations on payment.

State Law or Legal Theories Detrimental Reliance

Any applicable contract terms.

Example 2

St. Elsewhere Hospital rendered medically necessary services to Jane Doe from 11/15/13 – 11/16/13. A claim is timely submitted to ABC Insurance on 12/01/13. On 2/28/14, ABC denied the claim for lack of authorization/notification.

The hospital’s contract with ABC does not address pre-authorization of services or notification requirements for admissions.

What is our best argument?

ABC provided authorization. Provide documentation of any telephone

conversations or a copy of the electronic auth. Include name, phone #, and department of person

providing auth.

State Law MD Law requires that if the services are authorized,

absent certain factors, the plan may not deny reimbursement.

Any applicable contract terms.

In summary: The Patient Access Department is the key to an optimal

revenue stream. Ensure accurate data gathering at the time of registration.

Plan information-eligibility, coverage and benefit limitations. Authorization-active, valid auth for the services ordered. Thorough documentation will help with the appeals process.

Decrease the incidences of denials by effective pre-screening. Identify services that may be non-covered prior to them being

rendered. Identify services that require additional documentation development.

Increase the rate of clean claims.

The best defense is a good offense.

A successful patient access process will ensure that the facility has the funding it

needs to carry out high quality clinical care.

Disclaimer:Please NoteThe information conveyed in this presentation is for general educational purposes and is not legal advice. The application and impact of laws can vary widely, based on the specific facts involved. Given the constantly changing nature of state and federal laws, there may be omissions or inaccuracies in the information you receive during this program. Accordingly, any information is provided with the understanding that the presenter is not rendering legal, accounting, or other professional advice and services. As such, any information obtained in this presentation should not be used as a substitute for consultation with legal counsel or other professional advisors specifically retained for that purpose. While Fotheringill & Wade, LLC has made every attempt to ensure that the information contained in these materials is generally useful for educational purposes, Fotheringill & Wade, LLC and its agents & employees are not responsible for any errors or omissions or for the results obtained through the use of any information herein.