Transcript Denials, Appeals, Cash - Community Oncology Alliance

Getting More Cash Into Your Practice
CHOP
February 26, 2010
Objectives
 Learn More Techniques In Financial Counseling
 Bring More Cash In Through Appealing Denials
 Install Practice-Wide Cash Management
Market Trends
More patients are paying out-of-pocket
 Changes in self-payments including:
 Increased co-pays
 Coinsurance payments
 Deductible payments
 Out-of-pocket payments
for uninsured
Mean Health Insurance Costs Per Worker Hour for
Employees with Access to Coverage, 1999-2005
Source: Kaiser Family Foundation analysis based on data from the National Compensation Survey, 1999-2005, conducted by the Bureau of
Labor Statistics.
Out of Pocket Costs Are Too High (2005)
Percent of adults (age 19-64) reporting in past 12 months:
NOTE: Insured includes those with public or private insurance coverage.
SOURCE: Kaiser Commission on Medicaid and the Uninsured analysis of the Kaiser Low-Income Coverage
and Access Survey 2005: National All-Income Sample.
Market Trends
More patients are paying out-of-pocket
 Deductibles are growing due to HDHP’s.
 1.3 million have an HSA
(1% of total insured population)
 8.5 million have high deductible plans without
HSA’s.
(Per the Employee Benefit Research Group – 2006 Survey)
 $1 billion dollars invested in HSAs by Americans
(according to data gathered by inside Consumer-Directed Care (ICDC) newsletter Feb.
24 issue )
Impact of the Rise in Unemployment on Health
Coverage, 2007 to 2009
3.9
3.6
3.6%
=
National
Unemployment
Rate Increase
since 2007
(from 4.9% in
Dec-07 to 8.5% in
Mar-09)
Decrease in
Employer
Sponsored
Insurance
(million)
8.9
&
Medicaid Uninsured
/CHIP
Increase
(million)
Enrollment
Increase
(million)
Note: Totals may not sum due to rounding and
other coverage.
Source: John Holahan and Bowen Garrett, Rising
Unemployment, Medicaid, and the Uninsured,
Uninsured Rates Among Nonelderly
by State, 2007-2008
NH
VT
WA
MT
MN
OR
WY
NV
CA
AZ
MI
PA
IA
NE
IL
CO
KS
NM
TX
OH
TN
RI
VA
MD
NC
DC
SC
AR
AL
NJ
CT
DE
WV
KY
MS
AK
IN
MO
OK
MA
NY
WI
SD
ID
UT
ME
ND
GA
LA
FL
HI
National Average = 17%
<14% Uninsured (18 states & DC)
14 to 18% Uninsured (18 states)
>18% Uninsured (14 states)
SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 and 2009 ASEC
Supplements to the CPS., two-year pooled data.
Physicians’ Net Income from Practice of Medicine and Percent
Change vs. Private Sector Occupations (1995, 1999, 2003)
Average Reported Net Income
(dollars)
Average Net Income, Inflation
Adjusted (1995 dollars)
1995
1999
2003
1995
1999
2003
1995
1999
2003
All Patient Care
Physicians
180,930
186,768
202,982
180,930
170,850
168,122
-5.6%*
-1.6%
-7.1%*
Primary Care
Physicians
135,036
138,018
146,405
135,036
126,255
121,262
-6.5*
-4.0*
-10.2*
Specialists
210,225
218,819
235,820
210,225
200,169
195,320
-4.8*
-2.4
-7.1*
Medical
Specialists
178,840
193,161
211,299
178,840
176,698
175,011
-1.2
-1.0
-2.1
Surgical
Specialists
245,162
255,011
271,652
245,162
233,276
224,998
-4.9
-3.6
-8.2*
N/A
N/A
N/A
N/A
N/A
N/A
4.3
2.5
6.9
Private Sector
Professional,
Technical,
Specialty
Occupations^
Percent Change in InflationAdjusted Income
*Rate of change is statistically significant at p<.05.
N/A: Not available.
^The Bureau of Labor Statistics (BLS) Employment Cost Index of wages and salaries for private sector “professional, technical and specialty”
workers was used by the Center for Studying Health System Change (HSC) to calculate estimates for these workers; significance tests were
not available for these estimates. HSC calculated inflation-adjusted estimates using the BLS online inflation calculator
(http://146.142.4.24/cgi-bin/cpicalc.pl).
Source: Center for Studying Health System Change, Community Tracking Study Physician Survey, Losing Ground: Physician Income, 19952003, Tracking Report No. 15, June 2006, Table 1, at http://www.hschange.com/CONTENT/851/851.pdf.
Declining Physician Compensation
Source: MGMA Median Compensation Survey
Market Trends
 Below are the estimated recovery percentages by control
point for inpatients
 Pre-Admission (100%)
 Admission (75-80 %)
 Inpatient (65-75%)
 At Discharge (60-70%)
 One Month After Discharge (<40%)
 The bottom line is: when you are in the patient’s mindset,
you can collect!
What can you do to gain success in your collections
efforts?
Think that the Financial Counseling Process does not end until the $$ is in the bank
FIRST STEPS
 Ensure that your physicians are committed to
collecting money---that means they cannot give out
the double message to patients. It does not help
anything if they tell patients not to ever worry about
money. There message should be…”our financial
counselor will assist you with finding ways to pay for
your care…”
 Nothing will improve without provider support.
Pre-Visit
 Collect demographic information.
 Collect insurance information.
 Explain conditions of treatment meaning financial terms.
 Clarify who is responsible for the bill.
 Verify insurance and benefits.
 Obtain authorizations and/or referrals for the services you
know about.
Insurance
Verification
Check
List
Patient has the insurance they say they do and it is primary with effective date


Insurance address for bill

Plan type: HMO/PPO/other

Deductibles impacting care delivered in the office, e.g. IV drugs, radiology, labs, chemotherapy
administration

Episodic patient cost sharing for care delivered in the office, e.g. flat copays for Rx; coinsurance
payments, amount

Lifetime, annual or episode out of pocket maximum

Catastrophic coverage (yes/no)

Benefit caps: lifetime or other

If possible, patients’ current status regarding deductibles and out of pocket maximums; current
progress toward caps

Insurer requirements: Prior authorization; certification; notification; case management, step
therapy

Specialty pharmacy preference for patient costs, pharmacy billing.
Do You Want to Treat?
 Insured patients---yes!
 Underinsured/ uninsured
 Do they have $$$ or assets? Will they pay?
 Do they qualify for Medicaid?
 Do they qualify for other assistance in your state?
 Can they be insured by patient assistance or Foundations?
 Can they go on a trial?
Remember: Foundations will fund premiums
only if there is a specific request
Process Improvements:
Pre-Visit
If uninsured, begin the process before the patient
arrives…
“To best serve you at this practice, we
need for you to bring in your tax returns
for the last three years or another form
of proof of income when you come to
the office for your first visit. We can try
to get funding for your treatment, if you
qualify…”
Process Improvements:
Pre-Visit
 Deliver a consistent message to
patients about their financial
responsibility and continually educate
them on their specific benefit plan.
Each patient that visits should sign a
conditions of treatment that includes:
 Obligation to pay patient costs
 Obligation to obtain referrals
 Obligation to inform you of change in
insurance, employment or care status
 Be party to a collection effort, if they fail
to pay their bill.
Process Improvements:
The First VISIT
Provide detailed explanations where appropriate.

Train registration staff on how to present the conditions of treatment forms
and create scripts to support the process

Allow time in the registration process for the registrar to more fully review
the forms with the patient or consult with the financial counselor.

Have the forms signed and return a copy to the patient.
 Use a Patient Financial Obligation Statement that they should sign
prior to their first TREATMENT
 Tip: Statement content can vary from illustrating co-pay,
deductible and coinsurance information to much more
complex calculations, such as those that regimen specific
and payer-specific (contractual database or use your ERA
data).
Process Improvements:
FIRST VISIT
 For insured patients, do the following:
 Review treatment plan thoroughly (if and when it is available)
 Explain treatment alternatives, if there are any.
 Calculate out-of-pocket costs if you know them and provide the patient





with approximate time frame for these costs.
Inform patient of the obligation to pay patient costs at the time of the visit, if
possible.
Take a deposit for the first round of chemo if it is occurring that day.
Take credit cards in case bills are not paid or if the patient prefers to pay by
credit card.
Answer any questions the patient or family may have.
Perform a credit check, if the patient will owe more than benchmark
amount (≥ $5000)
Process Improvements:
Patient Financial Counseling
Collecting money from patients can be both a challenge and a
delicate situation if not handled properly.
 Remember their care
is a higher priority
than collecting
payment, but
collecting cannot be
ignored.
Process Improvements: Financial
Counseling
 Sample script with insurance:
“We have verified your benefits.The good news is your
insurance company is covering the majority of your bill.
Today all you are responsible for is $XX. How would
you like to pay today: cash, check, or credit card?”
 Increase points of collections----ever thought of
putting an ATM outside of your office or in the
waiting room?
 REMEMBER: Patients with insurance often
think their bills are paid!
Uninsured and Underinsured: The Visit
 These patients can be treated in the hospital---but do not
give up too easily…they need a financial interview and
they need to bring the following:
 Three years of tax statements or proof of income
 Statements of working assets---IRAs, 401K, life insurance,
annuities, etc., if you consider them r the programs for the
patients do
 Bank references for patients who have a high self-pay balances
 Credit cards
 Proof of Medicaid rejection, if they are going the PAP route
High Balance Patients—The VISIT
 UNINSURED PATIENTS: DO THEY QUALIFY FOR PAP or
FOUNDATIONS?
 The 2009 Poverty Guidelines for the
 48 Contiguous States and the District of Columbia
 Persons in family
 1
 2
 3
 4
 5
 6
 7
 8

Poverty guideline
$10,830
14,570 = 500% = $72,050
18,310
22,050
25,790
29,530
33,270
37,010
For families with more than 8 persons, add $3,740 for each additional person.
High Balance Patients—The VISIT
 Some PAPs besides having an income requirement have an
asset requirement. What is this?
 Not the patient’s house or car
 Retirement funds: 401K, IRA, SEP
 Stocks, marketable securities
 Other real estate
 Other investment transactions
High Balance Patients—The VISIT
 Why do all of this?
 Manage the patient and provider expectations
 Get patient through the process faster…right now it takes a
long time
 Be prepared with next steps for patients who do not qualify
 But, bottom line, keep as many folks with you as possible.
Analyze
Value Stream Process Map
99% of the Process Time Involves Two Process Steps
Patient is referred
to Oncologist and
Dx/Tx determined
Patient
completes
patient portion
2160 min
(36 hrs)
Financial &
Insurance
Verification
32 min
Locate &
Evaluate
Assistance
Programs
Call/ascertain
Program
Requirements
62 min
44 min
Entire
application
submitted
Notification
of approval
or denial
11400 min
(190 hrs)
(7.9 days)
Practice
completes
office portion
33 min
1%
16%
Percent of Processing Time
Source: E-Expert Reimbursement Partners 2008 PAP Survey
83%
Alternatives for Patients
 Other facilities
 Clinical Trials
 Treat them anyway
 Working their assets---what?
Working Assets
 Viatical and Other Insurance Settlements
 Restructuring Retirement Funds
 Payment Plans
 Automatic Credit Card Withdrawals
What is a life or viatical
settlement?
 A life or viatical
settlement is a proven
financial strategy that
enables eligible policy
holders to sell their life
insurance to a funding
institution and receive a
lump sum of cash. This
also means the patient
does not need to pay
premiums.
What is the difference between a life and a
viatical settlement?
 Life settlements generally involve individuals over the age of
65.
 Viatical settlements generally involve individuals of any age
who are terminally or chronically ill.
Please note that the definitions of these terms vary by state.
Financial Counseling & collections
 The financial counseling process
does not end after the first visit.
 Any patient with an outstanding
balance over 30 days of over $5000
should be counseled.
 Alternatives involving credit and
assets should be offered.
 Also remember that some patients
will spend down to Medicaid
levels.
Increase your collections

Train your staff on how to ask for payment. Introduce
scripts if necessary. Prepared answers for the more
common objections for non-payment will give your staff
the confidence to be more assertive.
PUT INCENTIVES IN PLACE
 For lowering patient balances or DSO
 For successful PAP applications in less than 5 days
 For collection of patient balances over $5-10K
 For lowering the number of patients that are sent to the
hospital
 For overall reduction in DSO or denials
Who Makes A Good Financial Counselor
Make Everyone A FC
 Have a Contract Book at your Front Desk
 Pictures of Insurance Cards
 Pre-Auth, Referrals Needed With E-mails or Telephone
Numbers
 Employers Who Use, if Applicable
 Contract Copays and Deductibles
 In-network, Out-of-Network
 Contracted Rates (for billing)
 Contracted Pharmacies
 Discharge Area with scripts, appointments, and
charging.
 Signs in waiting room.
Best Practice: ESA “Gatekeeper”
 What is that?
 If you have physicians who give ESAs either because they do not
know the lab results OR they choose to ignore them, you need
one or more gatekeeper(s).
 This means that patients may not get ESAs until the
“gatekeeper” has approved them after reviewing the latest lab
result.
Denials Are All Around!
 Denied claims as a percent of claims 10% -15%
or more in many practices
 Medicare alone denies approximately 6.3% of all
line items billed
 Estimated cost to work a denial is $25 - $30 per
claim
PART A & PART B PROCESS
(Non-Expedited)
 Beneficiary receives the service
 Medicare contractor (fiscal intermediary or carrier or
MAC) issues initial determination explaining whether
Medicare will pay for a service already received.
 Beneficiary has 120 days to request redetermination
by contractor. Provider may also request
redetermination
 Appeals will be consolidated
 Time frame may be extended for “good cause”
 Contractor has 60 days to issue redetermination
PART B APPEALS
(cont.)
 If redetermination is unfavorable can request
a“reconsideration” by Quality Independent
Contractor (“QIC”)




120 days to request reconsideration
Beneficiary & provider appeals will be consolidated
Time may be extended for good cause
Must fill out a reconsideration form which is available at
http://www.cms.hhs.gov/cmsforms/downloads/cms20033.pdf
 QIC must issue decision within 60 days.
 Parties may request escalation to ALJ if time frame not met
 60 days to request review by ALJ
ALJ HEARINGS
 Hearings conducted by Medicare ALJs in DHHS Office of




Medicare Hearings and Appeals
Minimum amount disputed must be $120 in 2008; $124 in
2009.
ALJs are in 4 regional offices, not local offices
Must fill out the ALJ request form
(http://www.cms.hhs.gov/cmsforms/downloads/cms20034ab.pdf)
For Part A and Part B claims, ALJ must issue decision within
90 days – with exceptions
 No time limit if request for in-person hearing granted
ALJ HEARINGS (cont.)
For ALJ hearings under Parts A, B, C & D
 Amount of claim must be at least $120 in 2008 (changes
annually)
 Subject to annual increase
 Can aggregate certain claims
 Hearings conducted by video teleconferencing (VTC) if
available, or by telephone
 ALJ assigned to case has discretion to grant request for in-person hearing
APPEALS PROCESS – BEYOND THE ALJ
HEARING
 If ALJ decision is unfavorable, have 60 days to request an
Appeals Council review (address will be in the rejection
letter)
 Must be in writing within 60 days after the ALJ decision,
 Appeals Council reviews the record concerning only those issues, unless
unrepresented beneficiary requests.
 If Appeals Council decision is unfavorable, have 60 days to
request review in federal court
 Must meet amount in controversy requirement
 Amount may increase each year ($1180 in 2008)
CALCULATING TIME FRAMES
 Time frames are generally calculated from date of
receipt of notice
 5 days added to notice date
 Time frames sometimes extended for good cause,
examples include:






Serious illness
Death in family
Records destroyed by fire/flood, etc
Did not receive notice
Wrong information from contractor
Sent request in good faith but it did not arrive
MEDICARE ADVANTAGE APPEALS
 “Organization determination” is initial determination
regarding basic and optional benefits
 Can be provided before or after services received
 Issued within 14 days
 May request expedited organization determination if delay
could jeopardize life/health or ability to regain maximum
function.
 Plan must treat as expedited if requested by doctor
 Issued within 72 hours
MEDICARE ADVANTAGE (MA)
 Request reconsideration w/i 60 days of notice of the organization
determination.
 Reconsideration decision issued within
 30 days for standard reconsideration.
 72 hours for expedited reconsideration.
 Unfavorable reconsiderations automatically referred to independent review
entity (IRE).
 Time frame for decision set by contract, not regulation
 Unfavorable IRE decisions may be appealed
 to ALJ
 to MAC
 to Federal Court
MEDICARE ADVANTAGE (MA)
 Fast-Track Appeals to Independent Review Entity (IRE)
before services end for
 Terminations of home health, SNF, CORF
 Two-day advance notice
 Request review by noon of day after receive notice
 IRE issues decision by noon of day after day it receives appeal request
 60 days to request reconsideration by IRE
 14 days for IRE to act
MEDICARE ADVANTAGE
GRIEVANCE PROCEDURES
 Grievance procedures to address complaints that are not
organization determinations.
 60 after the event or incident to request grievance
 Decision no later than 30 days of receipt of grievance.
 24 hours for grievance concerning denial of request for
expedited review.
PART D APPEALS PROCESSOVERVIEW
 Each drug plan must have an appeals process
 Including process for expedited requests
 A coverage determination is first step to get into the appeals process
 Issued by the drug plan
 An “exception” is a type of coverage determination
 Next steps include
 Redetermination by the drug plan
 Reconsideration by the independent review entity (IRE)
 Administrative law judge (ALJ) hearing
 Medicare Appeals Council (MAC) review
 Federal court
PART D APPEALS PROCESS –
COVERAGE DETERMINATION
 A coverage determination may be requested by
 A beneficiary
 A beneficiary’s appointed representative
 Prescribing physician
 Drug plan must issue coverage determination as expeditiously as
enrollee’s health requires, but no later than
 72 hours standard request
 Including when beneficiary already paid for drug
 24 hours if expedited- standard time frame jeopardize life/health of
beneficiary or ability to regain maximum function.
EXCEPTIONS: A SUBSET OF COVERAGE
DETERMINATION
 An exception is a type of coverage determination and gets enrollee into the
appeals process
 Beneficiaries may request an exception
 To cover non-formulary drugs
 To waive utilization management requirements
 To reduce cost sharing for formulary drug
 No exception for specialty drugs or to reduce costs to tier for generic
drugs
 A doctor must submit a statement in support of the exception
PART D APPEALS - COVERAGE DETERMINATIONS
ARE NOT AUTOMATIC
 A statement by the pharmacy (not by the Plan) that
the Plan will not cover a requested drug is not a
coverage determination
 Enrollee who wants to appeal must contact drug plan to get a
coverage determination
 Drug plan must arrange with network pharmacies
 To post generic notice telling enrollees to contact plan if they disagree
with information provided by pharmacist or
 To distribute generic notice
PART D APPEALS PROCESS
NEXT STEPS
 If a coverage determination is unfavorable:
 Redetermination by the drug plan.
Beneficiary has 60 days to file written request (plan may accept oral
requests).
 Plan must act within 7 days - standard
 Plan must act within 72 hrs.- expedited
Then, Reconsideration by IRE
 Beneficiary has 60 days to file written request
 IRE must act w/i 7 days standard, 72 hrs. expedited
ALJ hearing
MAC review
Federal court





PART D GRIEVANCE PROCESS
 Each drug plan must have a separate grievance process to
address issues that are not appeals
 May be filed orally /in writing w/i 60 days
 Plans must resolve grievances
 w/i 30 days generally
 w/i 24 hrs if arise from decision not to expedite coverage
determination or redetermination
USEFUL WEBSITES
 www.medicare.gov
 www.medicareadvocacy.org
 www.healthassistancepartnership.org
Private Insurance Appeals
 Appeals process must be outlined in the contract.
 Sometimes, it is outlined on the payer’s web site.
 Do not contract with a payer unless you know their appeals
process.
Appeals Process: Internal
 Assess the denial and damage
 Gather data
 Draft letter
 Follow up
 Guerilla tactics
Guerrilla Tactics
 Involve a lawyer---if only a cc
 Employer/ Union
 For Medicare or Medicaid
 Local representation
 HHS Regional Office
 State Insurance Commissioner
 State Medical Society
 The Press
Stop the Bleeding
 Do you have a denial management strategy?
 Do you have an ERA (835) Analyzer?
 What are your top five denials by payer? by dollar
amount? by type?
 How do you prioritize denials? How long does it take to address
them?
 How many claims are improperly paid?
 What is your plan to improve your denial rate?
Find The Bleeding
 Front Desk
 Poor demographics
 No payer contact information
 Insurance changes not tracked
 Change of patient address
 Wrong guarantor
 No signature on financial commitment form
Find the Bleeding
 Insurance verification/ Billing
 Lack of authorization
 Patient not eligible
 MA not Medicare
 Insurance ceiling not identified
 Deductible fulfillment not tracked
 Coordination of benefits
 MSP
 Catastrophic coverage
Find the Bleeding
 Charge capture/billing
 Coding
 Billing for supervising physician
 Medical necessity
 Support for unlisted codes
 Timely filing
 Duplicate claims
 Inability to write off small amounts
Find the Bleeding
 Clinicians
 Change of diagnosis
 Poor charge capture
 Off-label use with no ABN
 Dictation delays
 No submission of hospital charges
Solutions
 Front Desk/ Financial Counseling
 Technology
 Eligibility/verification products
 On-line eligibility verification
 Insurance company websites
 Contract book
 Establish standardized registration polices, procedures, processes and
performance levels
 Ensure that registration staff is thoroughly trained
 Insurance plans and requirements prior to treatment
 Plan requirements, e.g., referrals, authorizations
 Importance of correct demographics
Solutions
 Charge Posting
 Computerized coding tools
 Updated charge capture/Superbills
 Claims editors
 Claims “scrubbers”
 Online access to Medicare policies for all providers
Strategies
 Advanced Financial Counseling is a real key to success…
 Focus on the problem as an organization-wide opportunity to





recover revenue---everyone has to participate!
Maintain an electronic folder of winning appeal letters and
make it an accessible library.
Invest in systems to track, work and report denials, e.g. 835
analyzers
Develop standards for reporting types of denials and
communicate this information
Assign responsibility for denials and reward people for
improvements in denial rates
Measure improvement on an ongoing basis.