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for “Keeping You In The
Know!”
APPEALS AND MEDICAID UPDATE ISSUE
Medicare Appeals – A process
For those of us who may not know, the appeals process is
quickly being seen as a long treacherous road.
Treacherous not only in getting there by sending out
complete, quality documentation, gathering the masses to
provide an initial argument of the denial but also through
the mere wait and concern of validating services you
knew wholeheartedly you provided in good faith and
with the utmost concern for the patient.
Nationwide per AHA
RACTRAC
data
through
August
2012, 71% of cases
appealed are still
awaiting
determinations.
Based on this, we
still have much to
learn and much to see.
UNPLANNED ARGUMENTS
Unknown at the time of denial review, providers are
discovering that any level of appeal can bring about new
issues for the denied claim such as a $3000 DRG
validation turning into an $8000 medical necessity
denial. Even though it is surprising at times, know your
chart and be ready for the unexpected. This scenario can
certainly impact your budget as you may need additional
assistance for issues outside of your area of expertise.
You never know what is in store on any case but once
again, know your charts, weak or strong.
PLANNING FOR THE NEXT STEP
Finally, it is important to spend time on your Level II
appeal submission to ensure everything is available for
Level III. It is possible to win with no hearing. In fact, it
is happening and providers are being rewarded with
overturn notices from the ALJ.
In speaking to many providers and reviewing various list
serves, there is success at the ALJ level. Keys to that
success have been being knowledgeable about the
patient. Remember every piece of evidence in the record
can be important. What is that evidence? For example,
what drugs are being administrated and why? What are
the interactions
of those drugs?
How do those
drugs impact
the conditions
being treated
as well as
other
conditions the
patient
may
have?
This
may sound small but remember you are building a
clinical case of clinical facts…know them.
Document your argument(s) for your case as a summary
and include your Medicare regulations or other official
guidance available and pertinent to your issue. If there
are some areas that may be slim in documentation, be
prepared in how to address them if any questions are
raised. The judge will need you to lead him through the
documentation in most cases so once again, know your
chart.
RECOVERY ANALYTICS NEWSLETTER * NOV 2012
EXTRA! EXTRA!
MEDICAID RAC
ALJ PAVES THE WAY!
On July 13, 2012, The Department of Health and Human
Services released a memo to FIs (Fiscal Intermediaries)
and MACs (Medicare Administrative Contractors)
stating specific directions in how denials deemed not
appropriate for inpatient level of care but ruled as
outpatient should be administered. Here are some fast
facts providers need to keep in mind to obtain payment
under Part B for these services:
1. The memo is stating payment for all services
rendered during the patient encounter.
2. Remember to ask that the case be paid with
FULL Part B outpatient (with observation) if
ruled not medically necessary for inpatient.
3. Ensure order for observation order is in the chart
and/or declarations by the judge appropriate –
you may still get OBS dependent on the ruling.
4. Submit a replacement claim with appropriate
outpatient charges (see www.palmettogba.gov
>resources>appeals for specific instructions for
their jurisdiction.
5. Follow case following ALJ to ensure repayment
underrate Part B to include ALL HCPCS code
with APC payment rates as appropriate.
6. Perform provider education on these types of
denials to eliminate future risk.
Medicaid RAC audits have begun or will be beginning
soon for providers. If you are unsure of your Medicaid
RAC status, check the CMC Medicaid RAC website at
www.cms.gov >State Medicaid RAC. You should also
look for information in your monthly or quarterly
Medicaid bulletins.
Here is the latest update for North Carolina posted in the
State Medicaid Bulletin in October 2012:
“…DMA partnered with its current post-payment review
vendor, Public Consulting Group (PCG), to be one of
North Carolina’s Medicaid RAC vendors. PCG will
perform audits on select Medicaid fee-for-service claims.
Initial audits for claims showing an overlap of services
for Medicaid beneficiaries receiving hospice care will
begin in October 2012.
Effective October 1, 2012, DMA has contracted with
HMS to become the second RAC vendor. HMS will
perform post-pay audits on inpatient and outpatient
hospital, long-term care, laboratory, x-ray and
specialized outpatient therapy claims. DMA will be
working with HMS to establish a schedule for RAC
audits and will publish notice in the Medicaid Bulletin
regarding the service types selected for audit prior to the
audit implementation period.”
*Per NCDHHS Expect possible education in December
and January.
There is much discussion on what the initial focus for the
Medicaid RACs will be and of course this will be state to
state. Certainly coding (absolutely DRG) and billing will
be a focus but where will clinical Medical Necessity fall.
This will be interesting as Medicaid guidelines for
Medical Necessity vary by state. This will impact the
approach and the focus. Some states have rules that relate
to hours such as 8 or 30 should be inpatient and some do
RECOVERY ANALYTICS NEWSLETTER * NOV 2012
not. The key will still certainly be meeting medical
necessity for the Inpatient or Observation Level of Care
and orders. Criteria such as Interqual and Milliman are
being utilized by some so ensure your patients are
meeting all indicators for Severity of Illness and Intensity
of Service and evidenced based practice standard,
internal practice guidelines, and/or you are utilizing
second Level Review with your internal or external
physician advisor.
This list for Review Contractors as provided by Payment
Error Rate Measurement (PERM) in their October 2012
update and plan for reviews in 2013, can help you better
attack audits and prevent denials for all payers. Keep
them in mind when submitting documentation and
fighting denials.
Six primary elements in medical/coding reviews:
–Adherence to State specific guidelines and policies
–Completeness of medical documentation
–Medical necessity determined based on documentation
–Validation that services were ordered
–Validation that services were provided as billed
–Correct coding based on documentation submitted
Medicaid RAC Potential focus areas as identified by
HMS (www.hms.com) for New Jersey include:
COMPLEX REVIEW TARGETS
Frequently miscoded DRGs:
 Ventilator Support of 96 hours or greater
 Extracorporeal Membrane Oxygenation
 Tracheostomy
 Operating Room Procedure Unrelated to
Principal Diagnosis
 Excision Debridement
 Stroke Intracranial Hemorrhage
Long Term Care audits:
 Patient Liability Reporting
 Claims Overpayment Review


Mutually Exclusive Services / Unbundling
Improper Service Units Submitted
In recent automated denials, the following trends have
been identified:
- Inappropriate denial on Outpatient Claims for
CO125 (NCCI Edit) subject to NCCI Version 18.2
without considering the appropriate version by claim
Date of Service. This has caused unwarranted automated
denials being received by providers. Review denials
received with close detail to claim Date of Service
ensuring the correct NCCI Edit Version was applied. If
incorrect NCCI Version applied it is appropriate to
appeal the denial.
- Inappropriate denial on Outpatient Physical,
Occupational, and Speech Therapy line items for CO125
(NCCI Edit) when there are no NCCI or MUE
edits applicable for the service listed on the Account
Number. It has been identified that the therapy service
has been edited against another Outpatient service with
same Date of Service on a different / separate
account. Review Automated Denials reported against
separate and/or different accounts with same Date of
Service, verify that documentation supports reporting
both services, if it is supported then it is appropriate to
appeal.
Editor and Writer
Sharon Easterling, MHA, RHIA, CCS. CDIP
Recovery Analytics LLC
704-779-8095
AUTOMATED REVIEW TARGETS
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Duplicate Claims Review
Transfer Cases
Claims Paid After the Patient Deceased
Newborn Billing Issues
www.recoveryanalyticsllc.com
*DISCLAIMER: This newsletter and its content are strictly
informational and should not be interpreted as legal advice.
RECOVERY ANALYTICS NEWSLETTER * NOV 2012