Researching the ultimate appeal letter 2.0

Effective Appeals 2.0

Researching the Ultimate Appeal Letter

Call in Phone Number: 712-432-0075

Access Number: 866886

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Copyright 2010 INTERSECT HEALTHCARE, INC.

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The Next IHI Appeal Education Event

Using Advanced Document Management Techniques to Create the Ultimate Appeal Letter

Brian McGraw, CEO

Wednesday, November 17, 2010 1:00 PM ESThttps://www.intersecthealthcare.com


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Advanced Document Management Techniques to

Create the Ultimate Appeal Letters(An Adobe Acrobat Workshop)


Researching the Ultimate Appeal Letter

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Denise Wilson MS, RN, RRTDirector Audit and Appeal Services

We can take your appeals to a higher level. Ask me how!

Introductions

Denise Wilson MS, RN, RRT Director of Audit and Appeal Services at

Intersect Healthcare, Inc. 28 years of healthcare experience in staff,

management, compliance, education, and denials and appeals positions

Personally managed several hundred Medicare appeals and presented dozens of cases at the Administrative Law Judge level with a 95% success rate


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Introductions

Intersect Healthcare, Inc. One of the nation's leading providers of

Payor Compliance and Audit and Denial Management software for healthcare providers.

Offers a comprehensive combination of denial and audit software, appeal services and education.

www.intersecthealthcare.com


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Appeal Education Offerings

Online Education - $550 per facility includes: Fifteen MS-DRG Appeal Templates from IHI Appeal Library Two hours of Dedicated Online Education with Appeals Staff with Denise Wilson Case Appeal walkthrough with one actual case, using the IHI appeal template

On Site Education - $1,600 per facility includes: All Intersect Healthcare Medical Necessity and Coding Appeal templates Dedicated training program on researching and writing the Ultimate Appeal letters using the templates as your

starting point Designing and defining your facility RoadMap to the ALJ Chart review, abstracting and document management techniques to highlight the most important issues


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Appeal Support Services

AppealMasters Outsourcing – from $250 per case

DRG Validation and Medical Necessity Experts A dedicated network of Physicians, Appeal Nurses and P.A.’s RAC through the QIC for one competitive case rate ALJ Hearing preparation and execution services available No minimums required Full access to IHI Library, AppealMasters Reporting on Realtime

Appeal Status, Wins and Results Simplified referral process through the VERACITYTM portal Guaranteed turnaround times Root Cause tracking for all referred issues


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Learning Objectives

Research regulations to support your winning argument.

Research payment and reimbursement guidelines. Research evidence based clinical practice

guidelines. Incorporate research into appeal letter templates. Drive your reviewers to a decision in your favor by

building a road map for your case. Become an ultimate appeals writer by following all

the leads and doing the research.

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Building the Foundation for Appeal

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Start with the Decision Letter (Following all the Leads)Excerpt from a Review Results Letter (HDI)

Download and save these sections of the SSA in your Appeals Documents library.

http://www.socialsecurity.gov/OP_Home/ssact/ssact-toc.htmTitle XVIII Health Insurance for the Aged and Disabled

Building the Foundation for Appeal


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Review the Reason for DenialExcerpt from a Review Results Letter (DCS)

Download and save the ICD-9-CM Official Guidelines for Coding and Reporting for these claims dates of service in your Appeals Documents Library.

Building the Foundation for AppealICD-9-CM Official Guidelines for Coding and

Reporting These guidelines are included on the

official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.

Updated annually. http://www.cdc.gov/nchs/icd/

icd9cm_addenda_guidelines.htm


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Researching CMS Regulations CMS Internet Only Manuals (IOM)

http://www.cms.gov/Manuals/IOM/list.asp

100-02 Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A 10 - Covered Inpatient Hospital Services

Covered Under Part A Definition of Inpatient Physician’s responsibility on deciding on Inpatient

admissionCopyright 2010 INTERSECT HEALTHCARE, INC.

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100-02 Medicare Benefit Policy Manual Chapter 6 - Hospital Services Covered Under Part B 20.6 - Outpatient Observation Services

Definition of Observation Services Coverage of Outpatient Observation Services


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100-03 Medicare National Coverage Determinations (NCD) NCDs are easier to find through the

Medicare Coverage Database (MCD) index http://www.cms.gov/MCD/overview.asp


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100-04 Medicare Claims Processing Manual Chapter 29 - Appeals of Claims Decisions 240 - Time Limits for Filing Appeals & Good

Cause for Extension of the Time Limit for Filing Appeals

250 - Amount in Controversy Requirements; Aggregation of Claims for Appeal


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Researching CFR Regulations Code of Federal Regulations (CFR);

42 CFR 400 and following Describes the Appeal Process including the

Administrative Law Judge process http://www.gpoaccess.gov/cfr/index.html


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Researching CMS Regulations National Coverage Determinations

Published by CMS Applies to all CMS providers/beneficiaries CMS Internet Only Manuals (IOM); 100-03

Medicare National Coverage Determinations (NCD)

http://www.cms.gov/MCD/overview.asp National Coverage

National Coverage Determinations (NCDs): Alphabetical Listing


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Researching CMS Regulations Local Coverage Determinations

Developed and published by MACs/FIs Applies to providers/beneficiaries residing

in the MAC/FI region Not allowed to be more restrictive than

CMS regulations ALJs do not have to abide by LCD

regulations http://www.access.gpo.gov/nara/cfr/

waisidx_08/42cfr405_08.html


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Researching CMS Regulations Local Coverage Determinations

http://www.cms.gov/MCD/overview.asp Local Coverage

LCDs By Contractor By State Alphabetically


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Researching CMS Regulations ICD-9-CM Coding Manual ICD-9-CM Addendums

(The National Center for Health Statistics (NCHS) and CMS) http://www.cdc.gov/nchs/icd/icd9cm.htm

Coding Clinics (AHA) http://www.ahacentraloffice.org/ahacentraloffice/shtml/

Products.shtml

CPT, CPT Assistant (AMA) https://catalog.ama-assn.org/Catalog/cpt/cpt_home.jsp


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Researching CMS Regulations RAC SOW p. 18

“When making coverage and coding determinations, if no written Medicare policy, Medicare article, or Medicare-sanctioned coding guideline exists, the RAC shall not use automated review. Examples of Medicare-sanctioned coding guidelines include: CPT statements, CPT Assistant statements, and Coding Clinic statements.”

http://www.cms.hhs.gov/RAC/downloads/Final%20RAC%20SOW.pdf


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Researching SSA RegulationsLimitation on Liability § 1879 of the ActExcerpt from Focused Review Denial (NGS)

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Researching SSA Regulations Limitation on Liability; Social Security Act § SEC. 1879 Sec. 1879. [42 U.S.C. 1395pp] (a) Where—

(1) a determination is made that, by reason of section 1862(a)(1) or (9) or by reason of a coverage denial described in subsection (g), payment may not be made under part A or part B of this title for any expenses incurred for items or services furnished an individual by a provider of services…, and

(2) …such provider of services…, did not know, and could not reasonably have been expected to know, that payment would not be made for such items or services under such part A or part B,

then to the extent permitted by this title, payment shall,…be made for such items or services …

http://www.socialsecurity.gov/OP_Home/ssact/ssact-toc.htm


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Researching CFR Regulations Determining Limitation on Liability (42 C.F.R.

§ 411.406)(a) Basic rule. A provider, practitioner, or supplier that furnished services

which constitute custodial care under Sec. 411.15(g) or that are not reasonable and necessary under Sec. 411.15(k) is considered to have known that the services were not covered if any one of the conditions specified in paragraphs (b) through (e) of this section is met.

(e) Knowledge based on experience, actual notice, or constructive notice. It is clear that the provider, practitioner, or supplier could have been expected to have known that the services were excluded from coverage on the basis of the following:

(1) Its receipt of HCFA notices…

(2) Federal Register publications…

(3) Its knowledge of what are considered acceptable standards of practice by the local medical community.

http://www.gpoaccess.gov/cfr/index.htmlCopyright 2010 INTERSECT HEALTHCARE, INC.

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Researching HCFA (CMS) Rulings Determining “acceptable standards of practice by the

local medical community” (HCFA Ruling 95-1) V. ACCEPTABLE STANDARDS OF PRACTICE--APPLICATION In

situations in which services or items furnished do not meet locally acceptable standards of practice, the provider, practitioner, or other supplier is considered to have known that Medicare payment for the services or items would be denied. Providers, practitioners, and other suppliers are always responsible for knowing locally acceptable standards of practice; their local licensure is premised on the assumption that they have such knowledge. Medicare payment to providers, practitioners, or other suppliers is premised on the presumption that they have such knowledge, as evidenced by their licensure. No other evidence of knowledge of local medical standards of practice is necessary.

http://www.cms.hhs.gov/Rulings/CMSR/list.aspCopyright 2010 INTERSECT HEALTHCARE, INC.

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Researching HCFA (CMS) Rulings Determining “acceptable standards of practice by the

local medical community” (HCFA Ruling 95-1) Continued… Medicare contractors, in determining what "acceptable standards of

practice" exist within the local medical community, rely on published medical literature, a consensus of expert medical opinion, and consultations with their medical staff, medical associations, including local medical societies, and other health experts. "Published medical literature" refers generally to scientific data or research studies that have been published in peer-reviewed medical journals or other specialty journals that are well recognized by the medical profession, such as the "New England Journal of Medicine" and the "Journal of the American Medical Association." By way of example, consensus of expert medical opinion might include recommendations that are derived from technology assessment processes conducted by organizations such as the Blue Cross and Blue Shield Association or the American College of Physicians, or findings published by the Institute of Medicine.


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Researching Acceptable Standards of Practice


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LCD from Highmark Medicare Services



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NCD for Cardiac Pacemakers (20.8) Second reconsideration for Cardiac Pacemakers (CAG-00063R2)

Decision Memo



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Evidence Based Guidelines; Position Statements Professional Associations

American College of Cardiology http://www.cardiosource.org



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Evidence Based Guidelines; Position Statements Professional Associations

American Thoracic Society http://www.thoracic.org/statements/index.php

Researching RAC Issues

RAC Demonstration Project http://www.cms.gov/RAC/

02_ExpansionStrategy.asp RAC Websites (CGI)


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Researching RAC Issues

Region A DCS http://www.dcsrac.com/IssuesUnderReview.aspx

Region B CGI http://racb.cgi.com/Issues.aspx

Region C Connolly http://www.connollyhealthcare.com/RAC/pages/

approved_issues.aspx

Region D HDI https://racinfo.healthdatainsights.com/Public1/

NewIssues.aspx


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Links

Social Security Act http://www.socialsecurity.gov/OP_Home/ssact/ssact-toc.htm

ICD-9-CM Official Guidelines for Coding and Reporting http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

CMS Internet Only Manuals (IOM) http://www.cms.gov/Manuals/IOM/list.asp

National Coverage Determinations (NCDs) http://www.cms.gov/MCD/overview.asp

Code of Federal Regulations (CFR) 42 CFR 400 (Appeal Process) http://www.gpoaccess.gov/cfr/index.html

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Links

ICD-9-CM http://www.cdc.gov/nchs/icd/icd9cm.htm

Coding Clinics (AHA) http://www.ahacentraloffice.org/ahacentraloffice/shtml/

Products.shtml CPT, CPT Assistant (AMA)

https://catalog.ama-assn.org/Catalog/cpt/cpt_home.jsp RAC Statement of Work

http://www.cms.hhs.gov/RAC/downloads/Final%20RAC%20SOW.pdf

Limitation on Liability; Social Security Act § SEC. 1879. [42 U.S.C. 1395pp] http://www.ssa.gov/OP_Home/ssact/title18/1879.htm

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Links

Determining Limitation on Liability (42 C.F.R. § 411.406) http://www.gpoaccess.gov/cfr/index.html

Determining “acceptable standards of practice by the local medical community” (HCFA Ruling 95-1) http://www.cms.hhs.gov/Rulings/CMSR/list.asp

American College of Cardiology http://www.cardiosource.org

American Thoracic Society http://www.thoracic.org/statements/index.php

RAC Demonstration Project http://www.cms.gov/RAC/02_ExpansionStrategy.asp

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Research Tips

Start with the Decision Letter Follow all Leads Match the Regulation or Guideline Year to the

DOS Develop a Library of Resources

PDF Documents Bookmark Web Pages

Create Reusable Appeal Letter Templates Include Acceptable Standards of Medical Care in

the Community the Regulation Year to the DOS


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Thanks for attending!

Research! Research! Research!

Download, Bookmark, Print, Save, Store, File, Organize, Share, Use - Appeal!

You can reach me at:

[email protected]

410-252-4343 ext 16

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