In September I raised the issue of whether the primary responsibility of Union Health Plan Commissioners is the protection of the Plan or the Union members? With LineCo (the Union), the Plan requires completion of a course of treatment in order for any benefits to be paid out.
The case involved a member who had completed inpatient treatment near the end of one month and was scheduled for outpatient follow-up in the subsequent month. The Plan benefits terminated at the end of the first month as the result of a layoff. The patient postponed the outpatient until he had saved the cash to pay for it. The Union denied the inpatient claim despite the patient having complied with all other DC plans. Our challenge was that the Union was not entitled to Protected Information after their Plan no longer covered the patient. The interpretation of the lawyers was that a request for information after coverage terminates is not unreasonable for a month or two, but that a protracted requirement could be a violation of HIPAA.
Tuesday, November 10, 2009
One Lesson Learned
If an insurance company is allowed to stall the progress of an appeal for months through gross misrepresentation and incompetence, should they then be allowed to deny a claim for having maxed the prior year's benefits while the appeal was ongoing?
Value Options and Great West just did that and I am not sure why the government keeps giving these guys contracts, nor do I want to speculate on that. They initially denied a claim out-of-network and would not authorize the care despite the fact that they had no in-network facility within 80 miles. Appearing to have won the initial appeal, the claim was then stated to have been "pended" for a contract set-up problem. This was followed by: a billing issue; a dispute over which company was responsible to pay; and two months later denied as the patient had maxed their benefits a month after the treatment at our facility seven months earlier. We are still fighting this but one lesson learned is...
When appealing a claim, particularly one with a known day or dollar max, demand that the proceeds at issue be legally "pended" until all appeals and legal options have been exhausted.
Value Options and Great West just did that and I am not sure why the government keeps giving these guys contracts, nor do I want to speculate on that. They initially denied a claim out-of-network and would not authorize the care despite the fact that they had no in-network facility within 80 miles. Appearing to have won the initial appeal, the claim was then stated to have been "pended" for a contract set-up problem. This was followed by: a billing issue; a dispute over which company was responsible to pay; and two months later denied as the patient had maxed their benefits a month after the treatment at our facility seven months earlier. We are still fighting this but one lesson learned is...
When appealing a claim, particularly one with a known day or dollar max, demand that the proceeds at issue be legally "pended" until all appeals and legal options have been exhausted.
Thursday, September 3, 2009
Days Awaiting Placement
Medicare HMO payers are not necessarily experts in Medicare regulations nor are national companies contracted to provide Medicaid benefits experts on each state's regulations. ARA isn't an expert in all aspects of these regulations either, but we do the research as patterns develop.
One such Medicare pattern most hospitals have encountered is the scenario in which a payer denies care after the acute phase is over even when a skilled nursing facility is warranted, but placement is delayed . Your clinical staff acknowledges this, the chart documents your efforts and placement delays, but basically you cannot get further authorization.
A CMS July 2006 provision found in the "Medicare Claims Processing Manual Chapter 3 - Inpatient Hospital Billing; 40.2.2 - Charges to Beneficiaries for Part A Services; C - Inpatient Care No Longer Required" states that:
…that the beneficiary no longer required inpatient hospital care. (For this purpose, a beneficiary is considered to require inpatient hospital care if the beneficiary needed a SNF level of care but an SNF-level bed was unavailable.) The hospital cannot issue a notice of noncoverage if a bed is not available. Medicare pays for days awaiting placement until a bed is available…
In the case of non-Medicare situations similar to the above where the payer refuses further authorization at the current level of care, we suggest you consider an ad hoc agreement (See "Ad Hoc" blog) for a lower level of care rate, unless the payer is simply wrong. For example in Texas if Child Protective Services extends a stay, out of state contractors do not always know that the hospital is entitled to 3 extensions of 5 days each.
One such Medicare pattern most hospitals have encountered is the scenario in which a payer denies care after the acute phase is over even when a skilled nursing facility is warranted, but placement is delayed . Your clinical staff acknowledges this, the chart documents your efforts and placement delays, but basically you cannot get further authorization.
A CMS July 2006 provision found in the "Medicare Claims Processing Manual Chapter 3 - Inpatient Hospital Billing; 40.2.2 - Charges to Beneficiaries for Part A Services; C - Inpatient Care No Longer Required" states that:
…that the beneficiary no longer required inpatient hospital care. (For this purpose, a beneficiary is considered to require inpatient hospital care if the beneficiary needed a SNF level of care but an SNF-level bed was unavailable.) The hospital cannot issue a notice of noncoverage if a bed is not available. Medicare pays for days awaiting placement until a bed is available…
In the case of non-Medicare situations similar to the above where the payer refuses further authorization at the current level of care, we suggest you consider an ad hoc agreement (See "Ad Hoc" blog) for a lower level of care rate, unless the payer is simply wrong. For example in Texas if Child Protective Services extends a stay, out of state contractors do not always know that the hospital is entitled to 3 extensions of 5 days each.
AD HOC LLOC
DON’T GO INTO HOC…AD HOC
Too many facilities are retaining patients at the current level of care after further care at this level has been denied by the payer. The alternative is to provide the level of care your clinical staff believes is warranted and empower your designated staff (e.g. UR, UM) to negotiate an ad hoc agreement with the payer at a lower rate in lieu of discharging the patient. Clearly the rate you get is greater than a denial, but typically it is also greater than the net an appeal will yield.
Yes ARA is giving away a big tactical game plan. If your chart is not strong enough to support the higher level of care the odds of winning an appeal drops from 80+% to less than 50%. The most common examples include negotiating rates from Acute to PHP, SNF or RTC. Sometimes your clinical staff will agree that a patient is no longer acute but their home situation is too precarious for the patient to return while attending PHP, or the family is unable to provide the care of a SNF or RTC, or simply a bed is not available. When a bed is not available for the lower level of care, these days are referred to as Days Awaiting Placement and have legitimate payment potential.
Too many facilities are retaining patients at the current level of care after further care at this level has been denied by the payer. The alternative is to provide the level of care your clinical staff believes is warranted and empower your designated staff (e.g. UR, UM) to negotiate an ad hoc agreement with the payer at a lower rate in lieu of discharging the patient. Clearly the rate you get is greater than a denial, but typically it is also greater than the net an appeal will yield.
Yes ARA is giving away a big tactical game plan. If your chart is not strong enough to support the higher level of care the odds of winning an appeal drops from 80+% to less than 50%. The most common examples include negotiating rates from Acute to PHP, SNF or RTC. Sometimes your clinical staff will agree that a patient is no longer acute but their home situation is too precarious for the patient to return while attending PHP, or the family is unable to provide the care of a SNF or RTC, or simply a bed is not available. When a bed is not available for the lower level of care, these days are referred to as Days Awaiting Placement and have legitimate payment potential.
Verifications
Here are some key items most verifications fail to include that result in avoidable denials:
- Eligibility – After you verify benefits call the employer to verify current eligibility. If your specialty requires you to maintain a patient’s confidentiality with respect to the type of treatment (e.g. CD or Mental Health), use the name and UPIN of the professional doing the H&P’s;
- Group Plans - determine if it is an HMO or PPO and who is doing the reviews for these.
DON'T ALLOW STAFF TO ASSUME THAT A NATIONALLY KNOWN INSURANCE COMPANY ONLY HAS GROUP PLANS. THEY DON'T!!! - Clearly delineate the type of Plan if not a Group:
- (1) Self-Funded Plans - determine if the managed care is an administrative organization (ASO). Get the name and contact number for the employer's HR staff (who should have been called for the eligibility verification).
- (2) Federal Government Plans - Ultimately recourse is legal action through OPM; time consuming and generally unproductive. ARA has had some success with alternate methods but be aware when you get these patients that your options are limited.
- Appeals – Ask how many internal appeals are available? Do these include the concurrent and expedited peer reviews? If yes, you may have no further internal appeal rights. After internal appeals are exhausted is there a next level of appeal to an IRO/ERO or to the Employer/Plan? Be sure to have this information available to UR/UM staff.
- Pre-existing - When applicable be sure to document and request a copy of the specific wording and time frames included. Some Pre-X are specific to diagnosis and treatment, while others are very general e.g. a condition which any reasonable person would determine existed...
- Preauthorization by Secondary Payers- Clarify the policy up front and ask for a copy of their policy and a written release from HIPAA compliance.
Secondary Payers' Pre-Authorization
Secondary payers requiring concurrent authorization with primary payers has been a growing phenomenon over the past year. We are of the opinion, not a legal opinion mind you, that a secondary payer should not require any authorization unless and until care has been denied by the primary payer.
The requirement for concurrent authorization for services already authorized and paid by the primary payer may be a violation of HIPAA. The intent of HIPAA, as we interpret it, is that protected information should not be irresponsibly disseminated. Payers will rebut that they are legally entitled to such data. This, however, is not the issue. The issue is whether the protected information is required for them to properly proceed with claims processing in these cases.
Assume a patient stay is 6 days, with charges of $1,000 per day all authorized and allowed by the primary at $600 per day after a $500 deductible at 80%. The primary pays $2,480 of the $3,600 allowed rate. We would expect the secondary to cover the patient liability of $1,120. If the secondary only approves 3 days what portion of the patient liability will they cover now? What is the purpose of a secondary payer, responsible for only the deductible, copayment and/or coinsurance reviewing a chart for clinical necessity? The clinical necessity had already been received, reviewed and authorized in full by the primary payer.
In the example above, the secondary reviewed the chart and denied some of the days authorized by the primary. The provider would now have to appeal this determination to recover the otherwise patient pay portion. This would involve a demand for the details of each payers’ written criteria, review process and staff involved in the review that led to the discrepancy in results. Beyond creating a potential legal battle, no justification for disseminating protected documents would have been demonstrated.
ARA suggests that you require secondary payers who demand a concurrent authorization to provide you with their written policy regarding this as well as a written HIPAA release.
The requirement for concurrent authorization for services already authorized and paid by the primary payer may be a violation of HIPAA. The intent of HIPAA, as we interpret it, is that protected information should not be irresponsibly disseminated. Payers will rebut that they are legally entitled to such data. This, however, is not the issue. The issue is whether the protected information is required for them to properly proceed with claims processing in these cases.
Assume a patient stay is 6 days, with charges of $1,000 per day all authorized and allowed by the primary at $600 per day after a $500 deductible at 80%. The primary pays $2,480 of the $3,600 allowed rate. We would expect the secondary to cover the patient liability of $1,120. If the secondary only approves 3 days what portion of the patient liability will they cover now? What is the purpose of a secondary payer, responsible for only the deductible, copayment and/or coinsurance reviewing a chart for clinical necessity? The clinical necessity had already been received, reviewed and authorized in full by the primary payer.
In the example above, the secondary reviewed the chart and denied some of the days authorized by the primary. The provider would now have to appeal this determination to recover the otherwise patient pay portion. This would involve a demand for the details of each payers’ written criteria, review process and staff involved in the review that led to the discrepancy in results. Beyond creating a potential legal battle, no justification for disseminating protected documents would have been demonstrated.
ARA suggests that you require secondary payers who demand a concurrent authorization to provide you with their written policy regarding this as well as a written HIPAA release.
Wednesday, September 2, 2009
Payers Rate Fixing
Years ago, in the time of the UCR, we uncovered patterns of a wide range of "allowed amounts" for the same services within close time proximity by Payers who claimed these rates were based on a national database. Ingenix was the most frequently mentioned along with Concentra and others. After a little review we found that Ingenix was owned by UHC and other major carriers submitted their databases to them. We questioned whether this was an anti-trust issue and no one batted an eye.
Heaven forbid providers share rate information. But I digress to my recent favorite topic of the double standards we must endure...for now.
A few months ago my eyes lit up upon reading that Ingenix, UHC and others had made a significant settlement regarding the rates used from these companies in a class action lawsuit. This was followed by the NY Attorney General Cuomo's investigations and most recently Rockelfeller's Senate Committee investigation. See the following link:
http://www.ama-assn.org/amednews/2009/07/13/bisb0713.htm.
Heaven forbid providers share rate information. But I digress to my recent favorite topic of the double standards we must endure...for now.
A few months ago my eyes lit up upon reading that Ingenix, UHC and others had made a significant settlement regarding the rates used from these companies in a class action lawsuit. This was followed by the NY Attorney General Cuomo's investigations and most recently Rockelfeller's Senate Committee investigation. See the following link:
http://www.ama-assn.org/amednews/2009/07/13/bisb0713.htm.
Tuesday, September 1, 2009
Timeliness Double Standards
The double standard and inequities in the application of timeliness by payers. Rather than being resolved, the issues and disparities have intensified in 2009 as evidenced by the following:
- Providers are required to maintain timeliness of claims even while the payers' review of your clinical appeals may be delinquent. You can win the appeal and still not get paid if the claim wasn’t kept “alive.”
- Providers are required to present written proof of their timely filings of claims, records, and appeals, while payers are not required to do so.
- Payers are reducing their claims processing and review staff while the number of claims and appeals increase. Payers then openly tell your staff to allow them more time as they are behind. They do this with total disregard for timeliness statutes and contract terms, knowing full well that their only penalty is paying interest and usually only after a provider demands it. Providers’ penalty for the same offense is denial of the entire claim at issue.
Some Solutions include:
- When told by a payer that correspondence or denials you have not received were mailed on a specific date, demand written proof of delivery to your facility. If there is a pattern of claimed correspondence that you have not received then notify the payer that without their proof of timely filing you will not accept timeliness denials in from them in the future.
- Keep a log of payers’ delays in payments, reviews, etc. and demand interest.
- Use the log with payers who are persistently untimely to let them know you will not accept a timeliness denial from them until they correct their ways. After they are done laughing tell them that they can deduct a penalty from your payment, if indeed you were untimely, at the same interest rate they would have to pay when they are late. (May be testing this approach in Texas real soon. Look for the outcome.)
Subscribe to:
Posts (Atom)