MEDICARE ADVANTAGE UPDATE

Transcription

1 MEDICARE ADVANTAGE UPDATE Shannon Pavel, RN--System Director of Case Management Jennifer Bartlett, CPAR--Clinical Appeals & Denials Coordinator Infirmary Health

2 Registration & Insurance Verification Account Management Utilization Review/Case Management Contract Management Billing Health Information Management Denials Management

3 MA UPDATE TOPICS o Modes of attack in MA processes ocampaign efforts for face to face meetings obi-weekly accountability calls ocounterintelligence fighting back using MA policy & favorable appeals scenarios oadditional recourse for providers oma tactics

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5 HOW DOES MEDICARE DO IT? One audit company Assignment of a provider contact Medical record request limits Standard Appeal process Look back limited to 3 years (except OBS vs. IP not being audited) Established timeframes

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7 HOW DO THEY DO IT? Multiple audit companies No ability to select a provider contact No established limits Appeal process varies by plan Look back limits established by plan Timeframes established by auditor

8 MA PROCESSES MODES OF ATTACK Concurrent status denials Coding audits DRG validation audits Readmission Audits/Denials

9 CONCURRENT STATUS DENIALS MA adopted business model: Deny, deny, deny, deny concurrently and then push everything to arbitration Purposeful unavailability by the payor for Peer to Peer discussions Utilizing one medical director for an entire market/region Unrealistic appointment times for P2P calls Forcing unrealistic expectations for Peer to Peer discussions Payor demanding that P2P discussions can only be done with an attending physician that has had hands on the patient Unwritten and unsubstantiated policies that hamstring the provider of service and sway all cases in the favor of the MA Payors issuing member directed denials & then refusing to deal with a physician advisor service utilized by the provider (unless the patient has signed an AOR)

10 CODING AUDITS & DRG VALIDATION Overturn the concurrent denial and approve inpatient status, but chase the win with a coding/drg validation audit Multiple audit contractors, multiple correspondence addresses Seeing denials overturned but having to continue to follow the account for weeks and months to ensure repayment advised of keying errors on their part Appeals follow up letters being sent to the payor in an effort to obtain results of the appeals, only to have the payor then process the inquiry letter as the actual appeal, and then deny for timely filing, citing the date on the follow up letter as the date of the appeal

11 PAYOR MEETINGS Bi-weekly teleconferences Internal employees (CM s, appeal coordinators, billers, etc.) submitting payor specific examples and feedback to a central person who will handle escalation with the payor reps to hold them accountable in the denials and appeals processes Scheduling recurring phone calls with the payor specific reps to keep the current account level issues in front of them and push to resolution Using payor policies in discussions to poke holes in individual cases where the payor has not responded or followed their own policy Looking at using some data from favorable determinations for future use in fighting similar scenarios that are not receiving favorable outcomes Face to Face Meetings Demanding face to face on site meetings with issues list of items being reported to the reps Meeting with top level executive and decision makers/key stakeholders within the payor Funneling categorical issues to these stakeholder groups for resolution Including our System Administrators and those involved in contracting in these high level meetings Demonstrating our due diligence to the key payor stakeholders and outlining next steps of escalating issues directly to CMS

12 READMISSION DENIALS/AUDITS Misinterpretation by the MA plans of the CMS readmission review rules MA plans denials for related rather than preventable MA plans lack of understanding of their own published and/or documented policies and procedures regarding readmissions

13 WHEN ALL ELSE FAILS.. Any controversy, dispute or claim arising out of or relating to your Provider Agreement ( Agreement ) or the breach thereof, including any question regarding its interpretation, existence, validity or termination, that cannot be resolved informally, shall be resolved by arbitration in accordance with this Section The arbitration shall be conducted in the county were the majority of the services are performed, in accordance with the Commercial Arbitration Rules of the American Arbitration Association, as they are in effect when the arbitration is conducted, and by an arbitrator knowledgeable in the health care industry. The Parties agree to be bound by the decision of the arbitrator. Provider Manual and Contract Notice of Dispute American Arbitration Association- Commercial Arbitration Rules Binding vs. Non-binding Settlement Negotiations Legal Fees

14 QUESTIONS AND ANSWERS Open Forum