"At Ease" with Managed Care Contracts and Denials Management

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1 "At Ease" with Managed Care Contracts and Denials Management Rebecca Corzine Tarr, RN, MBA, CPA President & CEO MedPerformance Learning Objectives How Big is the Problem? From a Managed Care Perspective? What is a Denial, Underpayment, Lost Revenue Know Your Contracts Terms Some Best Practice Contract Terms Denials Appeal vs. Provide More Information Software Solutions Learning Objectives Proactive management of denials by knowing your contracts Describe how understanding your contracts will help you avoid denials Identify ways to manage your denials throughout the revenue cycle 1

2 How Big is the Problem? A recent HFMA article stated that payers deny between 7-10% of all payments to hospitals and medical practices That means even small hospitals may have over $1 million in an open continual status of denial However, hospitals also reported most denied claims are overturned But at what cost? Not all hospitals have the same success rate What is a Denial From a Managed Care Perspective? A refusal to pay as a result of the provider not adhering to insurance company policies / procedures, or pending receipt of additional information What is an Underpayment From a Managed Care Perspective? Incorrect payment resulting from pricing inaccuracies or differences in contract interpretation 2

3 What is Lost Revenue From a Managed Care Perspective? Undetected Underpayments Incorrect payment due to incomplete or inaccurate billing Charges or codes are missing from the bill and are thus never considered for payment Proactive Denial Management by Understanding Your Contracts Understand the terms of all of your managed care contracts Read all contracts and handbooks referenced Provide feedback to the Managed Care department to include terms to reduce future denials Understand, and make a reference list of, all contract key items Know Your Contracts Terms Understand, and make a reference list, of all contract key items, including: Items that could impact payments Items that could cause partial denials, total denials, and lost revenue All types of payment information Requirements for preauthorization / certification Time limits for billing Payor specific bill edits Initial Claim Submission requirements 3

4 Know Your Contracts Terms Understand and make a reference list of all contract key items, including: Corrected Claim Submission requirements COB Submission requirements Separate Stop Loss Submission Requirements Attachments needed Some Best Practice Contract Terms If payment of a claim is denied for untimely filing or forlack of notification, the denial will be reversed if the Hospital appeals and can show all of the following: At the time of required notification or at time the claim was due, the Hospital did not know and was unable to reasonably determine that patient was a Member Hospital took reasonable steps to find out that patient was a Member, and Hospital promptly provided notification, or filed the claim, after learning that the patient was a Member Unilateral Changes It is common for an payor to give itself the authority to make unilateral changes in the middle of a contract term on the condition that the payor gives the healthcare provider 30 days notice This means that, the payor may, at its discretion, make changes to contract terms at any time, and only needs to provide 30 days notice to the provider of these changes 4

5 Vague Language If there is any vague language (i.e., language that is not exact or precise, and can be subject to interpretation) in the contract, ask the payor to replace such vague language with clear and unambiguous language Entire Contract While the Contract defines the rights and obligations hospital and payor, the details of those rights and obligations are often found in the payor s policies, procedures, and manuals that are incorporated by reference into the Contract Because the Contract will likely require that a hospital comply with these referenced documents, it would be wise to obtain written copies of all these documents, and review these documents thoroughly in advance of agreeing to any Contract terms Covered Services Carefully review how Covered Services are defined in the contract Carefully review the contract to see if the payor has carved out a subset of services from Covered Services Carved-out services can be problematic 5

6 Review the UM Program In order to review an payor s UM program, ensure you receive the UM program information in its entirety If a contract refers to the payor s UM program only by incorporating by reference the payor s policies, procedures, and manuals that address its UM program, request and review copies of such policies, procedures, and manuals Sample Language Regarding the UM Program Favorable Language: The Provider agrees to participate in and cooperate with the UM Program and QA Program (UM/QA Program) utilized by the payor, subject to the Provider s right to appeal any adverse decisions on behalf of itself or as an authorized agent on behalf of the Member. A copy of the MCO s UM/QA Program is attached to this Agreement as Exhibit A. Sample Language Regarding the UM Program Unfavorable Language: As a condition for payment for Covered Services, the Provider agrees to participate in and comply with the UM Program and QA Program, as amended by payor from time to time in its sole discretion, utilized by the MCO to promote the efficient use of resources. The Provider shall comply with and, subject to the Provider s right to appeal as provided in the UM/QA Program, shall be bound by such UM/QA Program. 6

7 Emergency Services Generally, emergency services are exempt from any prior authorization requirements However, pay close attention to how the contract defines emergency services and the timeframe for which they must notify the payor Readmission Rates Pay close attention to definitions of readmissions within the contract Readmission rates may partially drive reimbursement over time Standards for Review Review how the contract defines medical necessity, and the specific standards for it (e.g., whether local or national standards apply, if the services must fall within a range of acceptable practice, and/or if the service must be the least invasive or costly) Additionally, ensure that the definition of Covered Services is the same in the UM program documents and in the patient/resident materials 7

8 Appeals of UM Decisions Review the appeal rights whether in the hospital s capacity or as an authorized representative of the patient When the hospital appeals directly, the appeal rights and process will probably be set out in the contract, or a policy or manual incorporated by reference Denials to be Appealed Claim denied for elective service without preauthorization Denied days, service, or level of care due to no concurrent authorization Denied because Not financially responsible Not a covered service Untimely submission charge/procedure should be bundled Denials When Payors Need More Information Claim denied pending receipt of medical records Claim denied due to missing or inaccurate information Claim denied because of charge or coding issues Charges denied waiting for itemized bill Drug or implant denied reimbursement waiting on invoice Secondary payment denied waiting on EOB from primary payor 8

9 Software Solutions Do you have software to: Help you manage your contract terms Understand financial impact of contract changes Understand if you are being paid according to contract terms Manage your Denials Appeals Medical record requests Know the root cause of your denials MedPerformance Case Management & UM Education MedPerformance has a team of certified Case Managers who are available to provide onsite or offsite education and support MedPerformance also has experienced Physician Advisors to provide telephonic support to your Case Management Team 26 MedPerformance imad MedPerformance has a powerful and easy to use Denial Management System imad that can help you reduce your denials MedPerformance can help you with manage your denials with experienced staff Free Denial Assessment still available 27 9

10 28 imad Contact Information For more information, please contact: MedPerformance LLC Rebecca Corzine Tarr RN CPA President/CEO (813)