Did Anyone Check the Law? Raising Legal Issues in Medical Appeals

Transcription

1 Did Anyone Check the Law? Raising Legal Issues in Medical Appeals Tammy Tipton, President Appeal Solutions, Blanchard, OK MGMA has determined that Tammy Tipton and her spouse have a financial interest in in claims resolution. The content of this session has been reviewed and has been determined not to be a conflict of interest. 1

2 Learning Objectives Examine your practice's appeal letters to ensure your appeal is assessed from both a clinical and legal standpoint by the appeal reviewer Outline ERISA and the legal protections it offers in your commercial appeals Explain why legal compliance is especially pertinent to quality appeal review of out-of-network care 2017 MGMA. All rights reserved MGMA. All rights reserved Revenue Cycle Complexity We have denials and appeals at a number of stages: eligibility, referral/preauth/ur, claims and even refund requests. Each stage has a number legal requirements and contractual performance standards Revenue Cycle Dream Team: clinical and legal expertise 2

3 2017 MGMA. All rights reserved The New Appeal Review The number of administrative external appeals that do not require medical judgment but require legal review of procedures and applicable law has increased. Source: NAIRO Payer Appeal Dream Team: Clinical, coding and legal professionals 2017 MGMA. All rights reserved Step 1: Know The Process Appeals follow formal, written processes: Medicare Medicaid ERISA/PPACA State medical/insurance mandates, workers comp, PIP, external review 3

4 Know The Process Deadlines, filing requirements, payer-specific process guidance: Medicare FFS 5-Step Appeal Process: Redetermination, Reconsideration, ALJ, Medicare Appeals Council, Judicial Review PPACA Standardized Commercial Payer Process: Internal Appeals, External Revew and Judicial Review 2018 MGMA. All rights reserved Know The Process Don't miss the timely filing requirement: Maintain a database of high quality appeal letter templates that are available through the organization. Always include a disclosure request See Sample Letter A Request for Specialty- Specific Review Critereia 2018 MGMA. All rights reserved

5 Implicate The Law It is our position that failure to provide the requested information may violate state and/or federal claim processing disclosure laws or, in the minimum, non disclosure reflects a poor quality medical process which discourages treatment provider input. Disclosure standards are meant to ensure that all qualified parties have access to the information necessary to properly appeal an adverse determination MGMA. All rights reserved Good Process = Good Decision Rather than detailing what is and what is not considered medically necessary or establishing standards for distinguishing medical necessity from non-medical necessity, the ACA charges the secretary of the HHS with overseeing the processes by which such determinations are made. Source Defining Medical Necessity Under the PPACA Daniel Skinner 2018 MGMA. All rights reserved

6 Step 2: Citing Law Legal citations often trigger more in depth review and help cure payers of Form Letter Response Syndrome 2017 MGMA. All rights reserved Payer Compliance and Quality Review Key features of a high quality appeal process have been incorporated into law: Qualified reviewers peer-to-peer, unbiased reviewers Disclosure of information used in decisionmaking Prompt decisions Escalation to independent review

7 Unbiased Qualified Reviewers For appeals involving MN, your case is reviewed by a Clinical Panel made of licensed healthcare professionals. Maximus Part A Medicare Appeals A plan's claims procedures must provide for the identification of medical (or vocational) experts whose advice was obtained in connection with an adverse benefit determination. DOL EBSA FAQ D Payer Compliance and Quality Review Clinical clinical documentation and letter(s) of medical necessity addressing efficacy/utility Supporting evidence medical literature, coding guidance/industry standards Regulatory citations managed coverage and disclosure laws, prompt payment deadlines, full and fair review/de novo requirements Contract terms

8 Denial Disclosure Requirements The reason or reasons for an adverse determination or final internal adverse benefit determination includes the denial code and its corresponding meaning, as well as a description of the plan's or issuer's standard, if any, that was used in denying the claim. In the case of a final internal adverse benefit determination, this description must also include a discussion of the decision. - CCIIO Patient Bill of Rights Denial Disclosure Scenario MHPAEA Generally prevents health insurers that provide MH/SUD benefits from imposing less favorable benefit limitation on those benefits than applies to medical/surgical coverage NQTL Any limit to benefit scope/duration subject to nonquantitative treatment limitation parity requirements (geographic limits, facilitytype limits, network adequacy)

9 Denial Disclosure - Preauth FAQ9: Health plan requires preauth for ninth visit for depression. What can I request for compliance with MHPAEA? Summary Plan Description (SPD) Specific Language regarding preauth Specific underlying processes, strategies, all evidence considered Analysis of how NQTL complies with MHPAEA More MHPAEA Impact CHIP, Medicaid benchmark benefit plans and managed care plan that contract state Medicaid programs must comply. Cite: federalregister.gov/documents/2016/03/30/ /medicaidand-childrens-health-insurance-programs-mental-health-parity-andaddiction-equity-act-of UCR calculation must comply. Sample Appeal Letter B -parity-investing-behavioral.pdf

10 Prompt Appeal Decisions Appeal Decision requirements Medicare FFS A/B 60/60/90/90 and Federal District Court calendar Commercial (HHS rules): Internal preauth/claim/urgent is 15 days, 30 days and 72 hours. Sample Letter C Internal/External review standard 60 days Source: Claim vs Refund Appeals RAC, ZPIC extrapolations can be appealed MaxMed Healthcare Inc v Burwell CMS manual states that it does not require the most accurate estimate Submit an expert's opinion as soon as possible, preferable during redetermination Source: 3 Takeaways from the Recent Ruling in Statistical Extrapolation in CMS Audits (sftp.polsinelli.com/publications/healthcare/resources/upd0216-5hc.pdf)

11 Contract Terms to Cite: What is Appealable? Appeal quality review protections Recognized clinical standards Fee Schedule, outlier payments and benefit calculations Accountable Care Organization contracts may contain customized language specific to the plan design Step 4: Assess Escalation The Intangible vs Tangible Rewards of Patient Advocacy in the Appeal Process 2017 MGMA. All rights reserved

12 What is Appealable? Determine quality of appeal review Escalate poor quality reviews to external review Does the payer's policy inhibit your organization's standards of care Can this be addressed during contract review and/or contract negotiation? Can pressure be added to payer via appeals? What is Appealable to IRO? Final determination should contain instructions for accessing next level of review Medicare Appeal Authorization The representation's signature must be dated within 30 days of beneficiary PPACA Model Notice of Adverse Benefit Determination has authorization area

13 Who Should Appeal? Provider, patient or patient advocate? Providers have been encouraged to assume this duty on behalf of the patient Caring about patient includes caring about appeal review quality Do new quality protections warrant rethinking this strategy and how can the best process be utilized and progress tracked? Who Should Appeal? Priority given to Medicare beneficiary appeals: OMHA's goal is to adjudicate Beneficiary and Enrollee appeals within 90 days (exc Part D denials are 10 days) Providers appeals sit in scheduling for years. OMHA is adding attorney adjudicators to process 24,500 appeal per year starting this year

14 Internal Appeals External Appeals Bias is often anticipated Relies on internal guidelines Decisions are primarily worded only to convey outcome Often performed by inhouse personnel at little cost to payer Strong bias protections Relies on internal guidelines and evidence-based research Decisions are meant to communicate outcome, how decision was reached and provide reviewer's credentials Average cost - $600/review 2017 MGMA. All rights reserved Continuing Education ACMPE credit for medical practice executives. 1 ACHE credit for medical practice executives. 1 CME AMA PRA Category 1 Credits.. 1 CPE credit for certified public accountants (CPAs). 1.2 CEU credit for generic continuing education. 1 CPE CODE: D A Let the speakers know what you thought! Evaluations will be ed to you daily MGMA. All rights reserved

15 Thank You Tammy Tipton Appeal Solutions P.O. Box 784 Blanchard, OK MGMA.ORG 15