DY574_261023_br. Indiana Association for Home & Hospice Care Reimbursement Meeting February 24, 2010

Transcription

1 Indiana Association for Home & Hospice Care Reimbursement Meeting February 24, 2010

2 Medical Necessity Reviews Providers have raised concerns regarding the need for signed MD orders to approve a request vs. diagnosis This requirement is not unique to Hoosier Healthwise MCOs and is required per 405 IAC For the 30 day post discharge treatment, an MD order is required on the discharge summary For ongoing treatment, a copy of the written plan of treatment signed by the attending physician must be submitted Page 2

3 Home Health PA Denials Providers have raised concerns regarding MCO medical necessity denials An analysis of the annual MCO PA denial rates for home health services reveals a low overall percentage of denials Anthem MHS MDwise Total 4% 4% 1% 3% Home Health Authorization Denial Rates CY 2008 Page 3

4 Medical Necessity Reviews OMPP contracted with Burns & Associates, Inc. to conduct an independent evaluation of prior authorization practices at the MCOs Part of the study included an audit of a sample of approved and denied authorizations at each MCO All cases were reviewed by physicians Authorizations for home health visits were included in the audit sample Across the MCOs for home health visits, the clinical reviewers agreed with the MCO medical necessity determination in the majority of cases Page 4

5 Transferring High Needs Members to MA-D Providers have requested that certain high-needs members receiving home health services be disenrolled from Hoosier Healthwise 405 IAC outlines the disability determination process The determination of whether a condition appears reasonably certain to continue throughout the lifetime of the individual without significant improvement is made on the basis of the expected duration of the condition There are four criteria the State reviews in order to make the disability determination: Applicant s functional limitations Applicant s age Applicant s education & training Applicant s work experience If the applicant is under 18 years of age, the applicant's condition is evaluated in terms of how it affects the applicant's activities and restricts the applicant's physical, mental, emotional, and social growth A condition which is likely to substantially impair a child s ability to become an independent and self-supporting adult is a basis for a finding of disability Page 5

6 Transferring High Needs Members to MA-D A parent or authorized representative must apply for disability determination to be enrolled in the Care Select program Accelerated review program currently in existence At time of application, the following information must be present Completed application Attestation by physician that condition is present and expected course Evidence of the condition Chromosomal testing results from lab Genetic testing results from lab Physiologic or structural abnormalities evidenced by testing reports Examples of accelerated review conditions Congenital malformation syndrome, multi-system Cri-du-Chat Down syndrome Hurler s Syndrome Page 6

7 Anthem - Medical Necessity Reviews (1 of 2) Prior Authorization Process All home care services must be pre-authorized Call or fax request before services are rendered Intake Line (or Fax ) What to Submit with Request Most current 485 (signed if available) For services already in progress: include timesheets/records from the last 3 weeks of visits Any other clinical information to support the need for the requested services-in home medical necessity must be satisfied Page 7

8 Anthem - Medical Necessity Reviews, cont d Medical Necessity Criteria Used Indiana State Regulations Link to IAC website: Rule 16 (Home Health Agency) Rule 22 (Nursing & Therapy Services) See Article 5: Medicaid Services Medical Policy & UM Clinical Guidelines 405 IAC CG-Rehab-04 (PT) CG-Rehab-05 (OT) CG-rehab-06 (Speech) Others as applicable to request Note: All requests that do not appear to meet criteria are sent to an Anthem physician for a medical necessity determination. Page 8

9 MDwise - Medical Necessity Reviews MDwise utilizes the IHCP medical policy for home health & hospice medical necessity reviews as well as in-house clinical criteria (i.e. Milliman or Interqual). Medical necessity is based on many factors-- not solely on the member s diagnosis-- including previous treatment for the diagnosis, severity level, anticipated length of treatment. A physician-signed plan of treatment is required for home health & hospice prior authorizations. A provisional prior authorization of services is given while waiting for the physician-signed plan of treatment. Page 9

10 MHS - Medical Necessity Reviews For any request requiring a review by a clinical professional, MHS asks for clinical information to verify medical necessity reviews. Clinical information includes but is not limited to: history of symptoms, previous tried treatments, physician rationale for the service requested, testing results associated with the condition that has prompted the request for service authorization. Medical Necessity reviews are done with a hierarchy of criteria. MHS first reviews the IAC to help determine benefit coverage for requested service, if there is no clinical direction regarding coverage found in the IAC, MHS Utilization Management staff will then refer to MHS medical policy guidelines. If MHS medical policy guidelines do not provide direction then MHS will refer to Milliman Care Guidelines, a national accepted evidence based criteria for indication and appropriateness of needed medical services. According to 405 IAC (a)(1) services must be prescribed or ordered in writing by a physician. Page 10

11 30 Day Automatic Approval Post Discharge Providers have raised concerns that MCOs are not honoring the 30 day automatic approval post discharge 405 IAC indicates PA is not required for home health services provided by a registered nurse, licensed practical nurse or home health aide which have been ordered in writing by a physician prior to the patient s discharge from a hospital and that do not exceed 120 units within 30 calendar days of discharge from a hospital Page 11

12 Anthem - 30 Day Approval Post Discharge Anthem follows Indiana Administrative Code (IAC) provisions. We do not require PA for physician s written orders for home health services within 30 days of discharge, within limits set in IAC. Page 12

13 MDwise - 30 Day Approval Post Discharge Members who require home health after discharge from an inpatient admission do not require prior authorization for the first 30 days post discharge MDwise did have difficulty with one delivery system erroneously requiring prior authorization during the 30 day post discharge period of time, but we have recently resolved this issue. Page 13

14 MHS - 30 Day Approval Post Discharge MHS encourages use of home health care services post discharge to assure our members care needs are met following acute inpatient hospitalization. All Home Health visits require an authorization, unless the home health visits are for the first 30 days after being discharged from an inpatient hospital stay or member is less than 365 days (1 year) old. Page 14

15 Overhead Payments Providers have raised concern that overhead payments are not consistently paid by the MCOs The MCOs are required to reimburse for overhead payments Chapter 8 of the IHCP Provider Manual provides detailed instructions on billing for overhead charges All MCOs have confirmed compliance with these requirements A claims dispute should be filed with the applicable MCO for any nonpayment issues The Claims dispute process is dictated by the provider s contract with the MCO Out-of-network claims disputes must be sent to the MCO within 60 days of the provider s receipt of the MCO s claim determination Page 15

16 Anthem - Overhead Payments Anthem pays lesser of billed charges or fee schedule Provider needs to bill Anthem enough to cover both the visit and the overhead amount Anthem pays the State Fiscal Year Rates for Overhead and Home Health charges Page 16

17 MDwise - Overhead Payments MDwise follows IHCP guidelines for home health overhead rates. An overhead rate is paid for each encounter on the DOS. An encounter occurs when an RN, LPN, home health aide or therapist enters a home, provides a service in the home, then leaves. In early 2009, a few claims processed without the overhead but were later identified and adjusted to pay correctly. Page 17

18 MHS Overhead Payments Indiana providers receive an additional payment per visit referred to as an overhead payment or an administration fee, which is submitted on the claim as Occurrence Codes in fields If the provider does not bill with an Occurrence Code then they will not receive payment for overhead, just the code/modifier they billed. Providers are not allowed to bill a Revenue Code for reimbursement of overhead payments. Overhead payment calculations are date sensitive. The overhead payment is only allowed when the provider has submitted an occurrence code for that date of service. Effective for dates of service on or after 07/01/08, providers may only bill one overhead charge per provider, per member per day on Home Health Claims. Occurrence code 61 must be billed on the CMS1450 (UB04) in box If more than 1 occurrence code is billed for same date of service, only one overhead payment is to be paid per date of service. Indiana Home Health services are submitted on a CMS 1450 (UB04), bill type 33X, location code12 for home health. If the home health visit is for an RN, LPN, Aids, OT, PT, or ST, the claim cannot be submitted on a CMS DME and care coordination can bill on a CMS 1500 so long as the Provider s specialty is Durable Medical, Home Medical Equipment, or Care Coordination. Overhead will not be paid for services billed on a CMS Page 18

19 MCO Contacts Grievances & appeals should be routed to the appropriate MCO Anthem: Phone (866) Fax (805) MDwise: Please see the MDwise Quick Contact Sheet for the appropriate Delivery System: ov-quickcontact.pdf. MHS: MHS-4U4U Page 19

20 State Contacts After the MCO process is exhausted, providers can appeal on behalf of a member to the FSSA Hearings & Appeals Questions or concerns can be sent to OMPP through managedcare@fssa.in.gov The MCO appeal process should be exhausted first Page 20

21 Questions? Page 21