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.
1

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
ESTCopyright 2010 INTERSECT HEALTHCARE, INC.
2
Advanced Document Management Techniques
to
Create the Ultimate Appeal Letters
(An Adobe Acrobat Workshop)

Researching the Ultimate Appeal
Letter
3
Denise Wilson MS, RN, RRT
Director 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
4

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
5

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 issuesCopyright 2010 INTERSECT HEALTHCARE, INC.
6

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
7

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.
8

Building the Foundation for
Appeal9
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.htm
Title XVIII Health Insurance for the Aged and Disabled

Appeal
10
Review the Reason for Denial
Excerpt 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.

Appeal
ICD-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 “Co ding Clinic fo r ICD-9 -CM”
published by the AHA.
 Updated annually.
 http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
11

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
13

 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
14

 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
15

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
16

 National Coverage Determinations
 Published by CMS
 Applies to all CMS providers/beneficiaries
 CMS Internet Only Manuals (IOM); 100-03
Medicare National Coverage Determinations
(NCD)
 National Coverage
 National Coverage Determinations (NCDs):
 Alphabetical Listing
17

 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.ht
ml
18

 Local Coverage Determinations
 Local Coverage
 LCDs
 By Contractor
 By State
 Alphabetically
19

 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
20

 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
21

Researching SSA Regulations
Limitation on Liability § 1879 of the Act
Excerpt from Focused Review Denial (NGS)
22

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
23

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.html
24

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.asp
25

Researching HCFA (CMS)
Rulings
 Determining “acceptable standards of practice by the
local medical community” (HCFA Ruling 95-1)
Co ntinue d…
 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.
26

Researching Acceptable
Standards of Practice
27
LCD from Highmark Medicare Services

28
 NCD for Cardiac Pacemakers (20.8)
 Second reconsideration for Cardiac Pacemakers
(CAG-00063R2)
 Decision Memo

29
 Evidence Based Guidelines; Position
Statements
 Professional Associations
 American College of Cardiology
 http://www.cardiosource.org

30
 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)
31

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
32

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
 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
33

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
34

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
35

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
36

Thanks for attending!
Research! Research!
Research!
Download, Bookmark, Print,
Save, Store, File,
Organize, Share, Use -
Appeal!
You can reach me at:
dwilson@intersecthealthcare.com
410-252-4343 ext 16
37
Blog:
http://www.intersecthealthcare.com/index.php/category/blog/compliance-corner/

Researching the ultimate appeal letter 2.0

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