DRG Denials Medical Necessity and Payer Behaviors Kim

DRG Denials, Medical Necessity and Payer Behaviors Kim Alexander, RN, BSN, RAC and Appeals Coordinator Stephanie Brown, RN Revenue Recovery Specialist UK Healthcare

Faculty Disclosure • Kim Alexander and Stephanie Brown have not had any relevant financial relationships during the past 12 months.

Educational Need/Practice Gap = Importance of documentation specifics related to each patient encounter Need = Volume of denials, and ability to focus on actual deficits

Objectives Upon completion of this educational activity, you will be able to: • Distinguish the need for clear, concise documentation from MD for quality of care coordination. • Explain the connection of documentation and reimbursements. • Identify ways to improve documentation for defense of denials.

Expected Outcome • What is the desired change/result in practice resulting from this educational intervention? • The physicians will be able to translate into practice, the value of the snapshot only they can provide.

Health Insurance is a for profit business • The primary function of multi-billion dollar insurance companies is to make more billions for themselves and their investors. • Functions are outsourced, systems are not synchronized • Difficult to determine why claims not paid

Medical Necessity and Beyond

Denials Task Force *Total Billed Charges, per remit posted in AEOS

CC DENIALS 1/1/2016 -6/30/2017 **EXPECTED PAYMENT, INPT & OUTPT TYPE Count of Acct No Sum of Payer Amt Due Authorization 4434 $6, 498, 986. 68 Billing Error 3906 $5, 339, 340. 59 Coding 595 $490, 857. 29 Documentation 612 $1, 079, 300. 24 Max Benefits 159 $105, 287. 45 MD Credentialing 3 $6, 990. 75 Medical Necessity 404 $1, 038, 458. 45 1908 $1, 588, 288. 50 242 $243, 444. 60 12263 $16, 390, 954. 55 Other Timely Filing Grand Total

Medical Necessity Solutions: Why is it important now? • • Denial management best practice: front-end avoidance All payors have some type of medical necessity denials Lack of pre-authorization: the #1 patient access-related denial More federal dollars focused on compliance Outpatient growth will continue Future RAC audits will be auditing compliance with regional LCDs and NCDs Advanced Beneficiary Notice (ABN)

Relevant Definitions-why all the fuss?

Goal of Audits-Save Money

Proper Medical Necessity tools and processes ensure revenue integrity ü ü Mitigating compliance risks Improve staff efficiency Decrease write-offs Reduce future post- payment reviews and medical necessity audits ü Reduce the need for ABNs ü Ensure ABN process only takes minutes

WIIFM • What’s In It For Me? Ø Quality Measures—SOI(Severity of Illness) and ROM( Ø Value Based Modifier (VBM) Ø Medicare Physician Compare, Health. Grades. com, and more Ø Potential Employment Metrics/Payer Preferences Ø Medicare Spending per Beneficiary Ø Present on admission (POA) Risk of Mortality)

MYTHS v v ABN adds too much time No compliance risks Easier to work the denials on the back-end Can still manually manage payor requirements v Small claims do not impact the bottom line

Denials Best Practice • Prevention with Comprehensive Documentation NOT Denials Management with Appeals • According to the AHA, hospitals report that nearly three-fourths of appeals are sitting in the appeals process

Clinical – Operational. Financial Linkages

Process of Denials Management

The PROCESS • Why was it denied? • Can it be appealed? • Did we make a mistake? • Appeal • PREVENT

Why was it denied? o Incomplete submission of records o Incomplete signatures or consents o Incomplete documentation of medical necessity o Drugs given without a current order o Dosage or procedure not documented o Non-specific coding o Payer/Medicare guidelines not met o Required authorizations not obtained

Can it be appealed? • Do we have a complete record? • Is the documentation supportive of medical necessity? • Does the treatment meet the payer’s guidelines? • Were appropriate authorizations obtained? • Within the timeframe allowed for appeals?

Did we make a mistake? • • Is billing correct for the procedure/care provided? Is the status (inpatient or outpatient) correct and matching authorizations? Did we send the correct records with an audit request? Did we send any requested information timely?

The APPEAL • • • Complete identifying information (member, hospital, dates, issues, etc) REASON we want this case reviewed and expected outcome. Supporting documentation excerpts from the medical record to support the argument, applicable guidelines, unusual circumstances of the specific case, medical review literature or clinical study information any other information that may apply

PREVENTION • How can we prevent similar denials in the future? Ø Ø Identify the issue and possible trends Address trends and develop action plan Implement a corrective process Review for outcomes “Taking care of denials can be like swatting flies, when you should be shutting a window somewhere. ”

A TEAM Approach • Develop a noteform for dictations • Establish an internal audit process (example for Total joints and Cataracts) ü To review the documents before the patient is placed on the surgery schedule ü Provide feedback about documentation to the surgeons ü Track the authorizations, and mitigate future denials

COMPLETE vs INCOMPLETE Documentation

Medicare Guideline for Cataracts • Decreased visual function due to the cataract 1. Decreased ability to carry out ADL’s 2. Best corrected visual acuity of 20/50 or worse OR with additional testing shows decrease by 2 lines 3. The patient determines they can no longer function 4. Other causes of vision loss are ruled out 5. Significant improvement is expected 6. Patient education re. risks and benefits 7. Appropriate evaluation including comprehensive exam and ophthalmic biometry

Cataract Documentation Template for ADL’s

Orthopaedic Template- Joint Arthroplasty v Used to provide the guideline required elements of history and treatments prior to surgery. The form is available in AEHR

Intent vs Actual Documentation

Best Practice • What do you want to convey? • Many people- other than doctorsmay access the record. • When in doubt, specific is better than general.

A Partnership • Templates based on Medicare Guidelines (LCDs and NCDs) • Increased contact from UM in real time to ensure appropriate authorizations • Be aware of the policies and guidelines that are available for public knowledge • Utilize every opportunity to ensure that medical necessity it met or appealed on the front end

Project: Prevention • • Total joint project Cataract project Pacemaker audits Watchman Devices LESI procedures Cardiac Rehab PET Scan IAuth implementation

Sources • • Clinical-operational-financial linkage-Charleeda Redman, Optum Forum 2015 Relevant definitions WIIFM-John Zelem, MD, FACS, VP, Compliance and physician Engagement, Optum Forum 2015 Goal of audits-Save Money-John Hall, MD, CCO, Optum Forum 2015 ‘Taking care of flies…. . ” Krishna Ramachandran, CO, Downers Grove, DMG. https: //www. cgsmedicare. com/articles/cope 31711. html https: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network. MLN/MLNMatters. Articles/downloads/mm 3927. pdf