Sepsis is the #1 cause of death in U.S. hospitals, and insurance companies #1 payment denial. Why do we let the payers decide if you have a life-threatening infection?

In recognition of Sepsis Awareness Month, PayerWatch and AHDAM join together to present three Sepsis Denial/Appeal workshops. Sepsis is the leading cause of death in U.S. hospitals, and the lack of definition/treatment consensus between providers and commercial insurers is infuriating and dangerous. 

Join an expert faculty of Physician Leaders from Adventist Health, UNC Hospitals, Sound Physician Advisory, as well as CDI Nurses and Coders, and let’s challenge the #1 Payer Denial plaguing hospitals across the U.S. One complimentary registration will ensure you receive access to all three workshops. Please support the Sepsis Alliance and learn more at sepsis.org.

Sepsis Denial/Appeal Workshop 1

Thursday, September 15, 2022 | 1PM ET

Sepsis 2 vs. Sepsis 3 and How To Write a Successful Sepsis Appeal (Dr. Ossman, Dr. Smith, Denise Wilson) This webinar will cover the ongoing dichotomy of using Sepsis 2 or Sepsis 3 to clinically support a sepsis diagnosis and how to successfully appeal when the provider and payer are using differing definitions. Register Now

Sepsis Denial/Appeal Workshop 2

Thursday, September 22, 2022 | 1PM ET

Staying the Course in Sepsis Documentation and Avoiding Sepsis Diagnosis Challenges (Dr. Agvanyan, Christi Drum, Garnette McLaughlin) This webinar will cover how to successfully manage sepsis documentation when payers try to dictate the use of a single set of criteria to clinically validate the diagnosis. Learn how to successfully challenge that practice on appeal. Register Now

Sepsis Denial/Appeal Workshop 3

Wednesday, September 28, 2022 | 1PM ET

Sepsis Current State – How to Appeal When the Payer Gets it Wrong (Dr. Hassaballa, Dr. Smith, Denise Wilson) This webinar will cover sepsis definitions, sepsis treatments, the current state of sepsis denial issues, payer-defined sepsis criteria, how to appeal for Sepsis 3 when the payer denied inappropriately, and how to appeal Inpatient Admission denials for sepsis. Register Now

The post September Sepsis Awareness Month. Join us for three Sepsis Denial/Appeal workshops. appeared first on PayerWatch.

It is crucial to recognize and document acute blood loss anemia because the condition is a significant indicator of severity of illness impacting revenue, quality and performance metrics, and pay-for-performance measures.

You can click here for examples.

In the United States, the diagnosis of an adnexal or pelvic mass will occur in 5 to 10 percent of women in their lifetime. Although commonly benign, the risk for malignancy in an adnexal or pelvic mass increases with age.

This month’s Denial Smackdown, featured the case of a patient who suffered a 6-point drop in their hematocrit post operatively, experienced a 200 ml blood loss intra operatively, had significant adhesions noted intra operatively, developed tachycardia and hypotension post operatively and was diagnosed as having “acute blood loss anemia” by the attending gynecologist post operatively.
You can imagine our dismay with this denial for acute blood loss anemia.

Payer: UnitedHealthcare
Billed DRG: 742 Uterine & adnexal procedures for non-malignancy with CC/MCC
Proposed DRG: 743 Uterine & adnexal procedures for non-malignancy without CC/MCC
At Risk Dollars: $2542.17
Recovered Dollars: $2542.17
Disputed Diagnosis: ACUTE BLOOD LOSS ANEMIA (ICD10-CM D62)
What made this denial so outrageous

An anonymous reviewer diagnosed the patient with “hemodilution”. Common sense says that adding a medical diagnosis to a record constitutes the practice of medicine.
Evidence based literature cited by Appeal Masters to overturn the denial

Bleeding and Acute Blood Loss Anemia as found on: https://acphospitalist.org/archives/2012/02/coding.htm

“Even if the amount of blood lost following surgery is expected and routinely associated with the procedure, acute blood loss anemia is still present if anemia occurs.”

Additional arguments made by AppealMasters

“Discounting the clear and consistent documentation in the chart from the attending and physician as set forth (above) and substituting an alternative diagnosis as a cause of a patient’s symptoms or findings (significant drop in hemoglobin, notable adhesions intraoperatively, tachycardia and marked hypotension postoperatively which the attending physician clearly diagnosed as acute blood loss anemia) infringes dangerously close, if not in fact actually crossing the line of practicing medicine under most state statutes related to medical practice. It is concerning that the reviewer offers no credentials to confirm their qualifications to diagnose medical conditions.”

Result:

Initially billed DRG 742 and the diagnosis of acute blood loss anemia (ICD-10CM D62) “Acute Blood Loss Anemia” were validated as correctly coded and billed.
What You Can Do In Situations Like This

Make certain that you demand the reviewer’s credentials.
Make your manage care contracting and legal departments aware of the concerns that the removal or addition of a diagnosis entered by an attending healthcare provider in some states could be viewed as practicing medicine.
Engage your organization to report behavior like this to State Medical Boards and State Insurance Commissioners.
Keep good data regarding which companies engage in this behavior most frequently and work with your legal department to consider legal options to push back.
Stand up for your rights!

Would you have handled this situation differently?

We want to hear from you! Take this quick poll to tell us what literature you would’ve used or arguments you would have made. Please feel free to share with colleagues. We will combine answers and share in next month’s Denial Smackdown!

The post Denial Smackdown Volume One appeared first on PayerWatch.

Earlier this month, Brian McGraw had the opportunity to talk with the host of InterviewsNOW, Shereese Maynard, from HealthcareNOW Radio about payer denials and appeals.

Listen to the full interview with McGraw and Maynard:

The post Talking Payer Denials and Appeals on HealthcareNOW Radio appeared first on PayerWatch.

Earlier this month, Brian McGraw had the opportunity to talk with the host of InterviewsNOW, Shereese Maynard, from HealthcareNOW Radio about payer denials and appeals.

Listen to the full interview with McGraw and Maynard:

The post Talking Payer Denials and Appeals on HealthcareNOW Radio appeared first on PayerWatch.

by Denise Wilson, RN, MS, RRT, Vice President, Clinical Appeal Services, Intersect Healthcare

Reproduced with permission of ACPA

A large national insurance carrier, offering managed Medicaid plans, recently denied the inclusion of ICD-10-CM codes Z68.41, body mass index (BMI) 40.0-44.9, and E66.01, morbid obesity due to excess calories, as secondary diagnoses on an inpatient claim for a large health system in Tennessee. The deletion of said codes resulted in a down coding of the originally billed DRG 086, Traumatic stupor & coma, coma <1 hr w CC to DRG 087, Traumatic stupor & coma, coma <1 hr w/o CC/MCC. The down coding resulted in a loss of dollars in the amount of $1,717 in reduced payment for the provider hospital.

The Back Story. A 61 year-old patient on aspirin and Plavix presented to the hospital emergency department after falling at home and suffering a severe headache immediately after. The CT indicated multiple areas of subarachnoid hemorrhage. The patient was declared a trauma and admitted to the ICU. A Neurology consult confirmed the diagnosis of subarachnoid hemorrhage. Fortunately, the patient’s hospital course was uneventful and the patient was able to be discharged home after a few days.

As the provider coded the chart for billing, codes that were included as secondary diagnoses were ICD-10-CM codes Z68.41, body mass index (BMI) 40.0-44.9, and E66.01, morbid obesity due to excess calories. After all, this patient’s body weight as recorded on the bed scale was 123.1 kg and the patient’s height as reported by the patient was 170.1 cm for a calculated BMI of 42.5 (click here for the page). The treating physician included the diagnosis of morbid obesity in the medical history section of the patient’s history and physical.

Coding guidelines in place at the time of the claim submission were as such:

“Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented.” Clinical Significance of Obesity, Coding Clinic, Third Quarter 2011, p. 4

So, imagine the provider’s surprise when the payer denied payment of the ICD-10-CM codes for body mass index 40.0-44 and morbid obesity. How could a payer deny these codes when they are clearly substantiated in the medical record and there is a Coding Clinic guideline from 2011 that tells us that these conditions are always (not sometimes, but always) clinically significant and reportable when documented by the provider?

Yes, up until October of 2016 there was some conflicting information between Official Coding Guidelines and Coding Clinic where the Official Coding Guidelines stated “As with all other secondary diagnosis codes, the BMI codes should only be assigned when they meet the definition of a reportable additional diagnosis (see Section III, Reporting Additional Diagnoses).” That discrepancy was corrected in the Coding Clinic, Fourth Quarter 2016: Page 118, when the requirement of meeting the definition of a reportable additional diagnosis was removed from the Official Coding Guidelines. That change went into effect October 1, 2016. Therefore, this payer used an illegitimate reason for upholding the denial stating that the morbid obesity and increased BMI did not complicate the hospital stay (payer-speak for stating the diagnoses did not meet the requirements for reporting additional diagnoses).

But that’s not the worst of it. The story gets more interesting. The provider appealed the denial stating that the payer’s allegation is incorrect and in conflict with the 2011 Coding Clinic. Unfortunately, the payer was not in agreement with the provider clearly pointing out the error in the payer’s ways and upheld the denial stating that, “per coding guidelines, diagnoses that have no impact on patient care during the hospital stay are not reported even when they are present. (Coding Handbook 2016, page 34.)” The payer apparently believed this statement from the Coding Handbook took precedence over the Coding Clinic specific to Obesity and BMI.

On to Round Three. Fortunately, in the state where this occurred, the provider had the option to appeal outside of the payer’s purview to an independent reviewer in the form of the state’s Oversight Division. Finally, an opportunity to explain the reasoning behind the inclusion of stated codes to someone outside of the payer who should have the knowledge and understanding of the Coding Clinic that clearly states that Obesity and BMI are always clinically significant and reportable (coded) when documented by the provider.

But, wait. The story begins to move from interesting to very strange. The independent reviewer in the form of the state Oversight Division upheld the denial again. The stated reason? “The reported BMI was not based on actual measured height but on the patient’s reported height, and thus was not a reliable measure.” Yes, both the trauma team in the ED and the nurses in the ICU failed to have the patient with the subarachnoid hemorrhage stand up to get an accurate measurement of height. Instead, they relied on the patient’s reported height in their calculation of the BMI. The independent reviewer, who was the medical director at the Medicaid agency, claimed that people “of this person’s age tend to over report their height.”

The independent reviewer supported the unreliability of using the patient’s reported height in the BMI calculation by citing two studies:

1. Merrill RM, Richardson JS. Validity of Self-Reported Height, Weight, and Body Mass Index: Findings from the National Health and Nutrition Examination Survey, 2001-2006. Preventing Chronic Disease. 2009;6(4}:A121.
2. Magnusson K, Haugen IK, Osteras N, Nordsletten L, Natvig B, Hagen KB. The validity of self-reported body mass index in a population-based osteoarthritis study. BMC Musculoskeletal Disorders. 2014;15:442. doi:10.1186/1471-2474-15-442.

From my review of the studies above, the first study concluded that “men overreported their height by 1.22 cm (0.48 in)…and women overreported their height by 0.68 cm (0.27 in).” The second study, performed in Norway on people with and without osteoarthritis, “showed a strong dose-dependent association between a higher measured BMI and greater overreporting of height…” The study speculated that the overreporting of height in the elderly was likely due to the fact that the elderly tend to forget that they shrink as they age.

Fair enough. Let’s say our patient overreported their height by the greater average amount of 1.22 cm. That would mean the patient’s actual (or measured, had the care providers stood the patient up and obtained a measurement) height could have actually been 168.88 cm (instead of the reported 170.1 cm). That would give our patient a BMI of 43.2 (168.88 cm height, 123.1 kg weight); an even higher BMI than the 42.5 that was recorded in the medical record. So, underreporting of height actually skews the BMI higher to support a diagnosis of obesity. How could anyone with high school level math skills deny a legally assigned diagnosis code based on a tendency of the elderly to overreport their height by less than a half of an inch?

It’s hard to fathom how this could be happening, but it is. The provider will be taking this case next to arbitration. Here’s to hoping the arbitrator has some common sense and a basic understanding of simple math.

The post How Less Than a Half of an Inch Cost a Hospital > $1,700 in Denied Payment appeared first on PayerWatch.

By R. Kendall Smith, Jr., MD, SFHM

A report released by the HHS Office of Inspector General (OIG) in September 2018 found that Medicare Advantage Organizations (MAOs) overturned a jaw-dropping 75 percent of their own denials from 2014 to 2016. Even more startling was that independent reviewers at higher levels within the appeals system reversed originally denied claims, finding in favor of beneficiaries and providers.

Furthermore, 45 percent of contracts were cited by CMS for sending denial letters with incomplete or misleading information, which may have hindered providers’ or beneficiaries’ chances of prevailing with an appeal. What appears of immense concern in this report was the comment that CMS continues “to see the same types of actions in its audits of different MAOs every year.” More telling was that 76 MAO contracts overturned more than 90 percent of their own denials upon appeal, including seven contracts that overturned more than 98 percent.”

Given these astounding overturn numbers, one has to wonder why beneficiaries and providers appealed only 1 percent of denials to the first level of appeal—reconsideration by a Quality Improvement Organization or their MAO. The remaining 99 percent of denials go unchallenged despite an almost four out of five chance of prevailing on appeal.

In the words of Bob Marley: “Get Up, Stand Up, don’t give up the fight.” Stop letting money flow down the drain.

Learn how your organization can save time and resources amidst increasing volumes of Medicare, Medicaid, and commercial payer denials.

The post CMS Audits Highlight MAO Performance Problems Related to Denials appeared first on PayerWatch.

https://revenuecycleadvisor.com/news-analysis/note-speaker-denial-prevention-strategies-2018-revenue-integrity-symposium

The post Note from the speaker: Denial prevention strategies at the 2018 Revenue Integrity Symposium appeared first on PayerWatch.

Fed up with claim denials for inpatient admissions by Medicare Advantage (MA) plans months after they were approved, Self Regional Healthcare in Greenwood, S.C., complained to the CMS regional office in Atlanta.

“We started sending information to CMS saying that if the Medicare Advantage plans do concurrent review and authorize inpatient care, we have every right to expect payment,” said Roy Baker, M.D., medical director of case management. Otherwise, the hospital should have the right to hold the beneficiary liable for the hospital stay. That had an impact. “CMS cares about beneficiaries. They took that to heart and [went to] the Medicare Advantage plan,” Baker said at a March 8 webinar sponsored by Intersect Healthcare and AppealMasters. “In 24 hours, a group of denials was overturned in one fell swoop. It made my CFO happy.”

CMS intervention is one way the hospital fights MA payment denials, Baker said. It has found success in new ways, along with other hospitals that have used assorted strategies to protect their revenue from the increasing number of claim denials they say they are experiencing. Some are appealing claim denials on behalf of patients because they have far greater rights, said Brian McGraw, president of Intersect Healthcare and AppealMasters.

“If you fight and win on the patient’s behalf, you get paid, even if your own [appeal] rights are exhausted,” he noted.

Hospitals Appeal Denials for Patients

MA plans are denying claims after clinical validation audits and readmissions within 30 days, said Denise Wilson, vice president of clinical audit and appeal services at AppealMasters. They also often refuse to authorize inpatient admissions, instead approving longer stays in observation. Most don’t follow Medicare’s two-midnight rule, Wilson noted. “UnitedHealthcare jumped on it right away and, after a year, they said they are not doing it anymore,” she said.

There also are some quirks in MA policy manuals, which are referenced in contracts, Baker said. Although MA plans must follow Medicare local and national coverage determinations and other regulations, hospital contracts govern many aspects of the relationships between MA plans and hospitals. For example, UnitedHealthcare’s policy manual has a statement that hospitals must provide a home visit to ensure safe discharges, Baker said. “I don’t know how many hospitals can afford to do a home visit for every discharge, and I haven’t seen them enforce it for denials yet,” he said. “But be careful.”

Self Regional doesn’t participate in any MA plans, although obviously the hospital treats patients enrolled in MA plans and accepts their payments. “There is no advantage to [participation],” Baker said. Hospitals lose most of their appeal rights, and “you have to go by what they say rather than what CMS says.”

Baker has made a lot of headway with MA plans by escalating problems to CMS (see box below). For example, when MA plans disagree with a diagnosis, they downgrade MS-DRGs by removing a complication and comorbidity (CC) or major CC. In response, Baker asked CMS whether the MA plans reported the diagnosis changes so their own risk scores could be adjusted. After Baker raised the risk adjustment issue to CMS, “we got a group of claims overturned,” he said. “Risk scoring is way off.” CMS has been conducting risk adjustment data validation audits of MA plans, and the Department of Justice in February joined a False Claims Act lawsuit against UnitedHealthcare that alleges the MA company exaggerated patients’ risk factors to increase reimbursement.

One caveat about complaining to CMS: it only intervenes when hospitals don’t have a contract with an MA plan. Otherwise, CMS defers to contract terms, McGraw said.

Appealing for Patients Requires Authorization

Meanwhile, Baker also has seen improvement by going directly to the source—the MA plan—with help from the American College of Physician Advisers and South Carolina Hospital Association. “We now have friends at Humana. I never thought I would say this,” Baker remarked, noting the MA plan has a new regional medical director who “has been extremely helpful.” Humana also has a corporate compliance department that addresses CMS complaints.

His hospital also appeals claims on behalf of patients. This is a powerful strategy that’s underappreciated by hospitals, McGraw says. Unless they negotiate better terms in their MA contracts, hospitals typically have one level of appeal. But patients in MA plans have an internal grievance process and then the same five levels of appeal that hospitals and beneficiaries enjoy under traditional Medicare, McGraw says. “If you’re a provider, it’s internal review only,” he says. “But patients have the five steps of the Medicare process in Medicare Advantage plans.”

‘Soft Approach’ Is Recommended

The catch: Hospitals need patients’ authorization to appeal payment denials on their behalf. This isn’t a big deal, however. McGraw said they just have to ask patients to sign authorized representative forms, which can be added to existing registration or discharge forms. Self Regional Healthcare asks patients for authorization on admission paperwork and hasn’t gotten pushback from anyone, Baker said.

Asking patients to authorize the hospital to appeal claim denials on their behalf usually requires a soft approach, McGraw said. When hospitals don’t get authorization upfront, they may ask for it in a post-discharge letter. “We talk about the hospital service to the community, and inform the patient that the insurance company in its infinite wisdom has deemed the stay medically unnecessary or changed the diagnosis that the doctor selected, which we disagree with, and that we would like to appeal on the member’s behalf,” he said. “Often your language is about your caring for your patient, and hopefully the patient had a good experience at the hospital. But not everyone does, so you might want to check out whether they were a satisfied patient before you send it out.” Include a stamped, self-addressed envelope and keep the letter to one page, McGraw advised.

Whether hospitals do it upfront at registration or after the fact, this is pretty easy. “I don’t understand why hospitals aren’t doing it,” McGraw said. Even when they have the form in place, they don’t tend to pursue appeals on behalf of patients.

They think it’s too burdensome, but it’s the same appeal they file on their own behalf, plus an address change. Each MA plan may have its own authorization form, so hospitals must make sure they use the correct one, McGraw said. The forms are different from consent to treat and assignment of benefits forms.

Appealing on patients’ behalf should be part of hospitals’ payer dispute management approach, an organized method for protecting their MA payments that begins with the contract terms and takes them straight through the appeals process, McGraw said. The contract should set forth the levels of internal appeal, the time frame for submitting medical records and receiving a response, the name of the medical director and all the other details required for the hospital to manage its denials and appeal rights. “You will get denials whether or not they repeal Obamacare,” he said.

Contact Baker at roy.baker@selfregional.org, McGraw at bmcgraw@intersecthealthcare.com and Wilson at dwilson@intersecthealthcare.com.

The post Appealing Medicare Advantage Denials For Patients Gives Hospitals More Leverage appeared first on PayerWatch.