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

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In fiscal year 2017, insufficient documentation comprised the majority of estimated FFS improper payments in both Medicare and Medicaid, with 64 percent of Medicare and 57 percent of Medicaid medical review improper payments. The report indicated that Medicare FFS had an estimated $23.2 billion in improper payments and Medicaid FFS had $4.3 billon in improper payments in fiscal year 2017 all due to insufficient documentation.

Part of the reason for doing this study was to examine “Medicare and Medicaid documentation requirements and factors that contribute to improper payments due to insufficient documentation”. Essentially, one goal was to determine how insufficient documentation contributes to improper payments based on Medicare FFS versus Medicaid FFS requirements for medical documentation as there is often a huge discrepancy between what Medicare requires for medical documentation and what Medicaid requires for medical documentation, even for the same services.

Insufficient documentation is defined as instances in which providers submit documentation that is insufficient to determine whether a claim was proper, such as when there is insufficient documentation to determine if services were medically necessary, or when a specific, required documentation element, such as a signature, is missing. Instances in which providers fail to submit requested documentation or respond that they do not have the requested documentation is counted separately and reported as no documentation. No documentation errors account for a very small number of improper payments.

There were two things about this report that struck me as interesting and provided food for thought. First, why is there a huge discrepancy between Medicare and Medicaid documentation requirements for medical necessity of these services and how, or does, that correlate to appropriate assessment of program risks by CMS? Second, why is this so hard? Why are providers failing so badly at providing the payer with full and sufficient medical record documentation to support services billed in the first place?

Why the discrepancy in documentation requirements?

For Medicaid programs, states primarily set the standards for documentation requirements and often do not require documentation such as progress notes from referring physicians to support medical necessity. In contrast, Medicare requires supporting documentation from the referring physician for the four services reviewed in this report. And, while both programs require signatures on provider documents, only Medicare has detailed standards for what constitutes a valid signature.

Without an understanding of how differing documentation requirements affect improper payment rates, CMS may not be able to fully identify and address FFS program risks. CMS told the GAO that they have not assessed the implications of how differing requirements between the programs may lead to differing assessments of the programs’ risks. So do greater documentation requirements equate to lower program risks? Or, is Medicaid’s shorter list of required documentation doing the job to adequately protect against program risks? I think this report illustrates that we don’t know the definitive answer to that.

Why are providers failing at providing supporting documentation?

This was actually my first question as I was reading through the report. Why is this so hard? The report very clearly shows in graphical and narrative ways that the poor response to additional documentation requests has been an issue for at least a decade, likely longer, and is not improving. Why is that? Does CMS have any concern over looking into the factors, barriers, behaviors, or failed processes that could be causing this very large lack of provision of appropriate medical records to the payer? Does CMS even have any skin in this game to improve those poor response rates? And, when I say poor response, I don’t mean the providers aren’t sending medical records; I mean that providers aren’t sending medical records that fully and appropriately support the medical necessity of the services provided and meet the statutory regulations for documentation of certain services.

According to the report, CMS officials are aware that some service providers are at a disadvantage in having to rely on documentation from the referring providers to support medical necessity. And, referring providers have little incentive to provide supporting documentation as there is no financial repercussion for not providing it. The report indicates that CMS has provided education to physicians on the need for submitting supporting documentation, but not much else has been done to encourage improved compliance with requests for records.

So far, CMS has participated in the Patients over Paperwork initiative begun in 2017 to simplify providers’ requirements for documentation. And, the report states that, thus far, CMS has clarified and amended several Medicare documentation requirements, including requirements for duplicate documentation, to help decrease the provider burden on documentation. It remains to be seen how much impact this program may have on decreasing the documentation burden on providers in the coming years.

So, did you know that Medicare’s CERT and Medicaid’s PERM contractors make multiple attempts to contact providers to get the medical record documentation they need for medical reviews? Both contractors allow providers 75 days to submit documentation, but will accept late submission as long as they have not yet reached their deadline to finalize their findings. If there is no response to an initial request for medical records and supporting documentation, the contractors will make at least three additional contacts with the provider requesting the documentation. Three additional contacts! For Medicare, if the services are referred services such as home health, DME or laboratory services, the CERT contractor will also reach out to the referring physicians for documentation. Once the contractors do receive documentation, if it’s not sufficient, they will reach out again for additional documentation.

Despite all of these efforts, in fiscal year 2017, the CERT contractor requested additional documentation from 22,815 providers out of 50,000 claims reviewed. 56% of the time, no additional documentation was provided. This just baffles me. In it’s simplest form, it’s seems to be a break down in the communication process back and forth. In today’s day and age of instant communication it seems difficult to fathom that after all of the attempted contacts from one entity to another that an adequate response is still not forthcoming. Imagine if 56% of your texts never made it to their intended recipient or didn’t result in a requested response from the receiver. With such poor response rates I can’t help but wonder how many dollars are being denied that could have been appropriately paid had the requested documentation been supplied.

I’m sure the current process of asking for and receiving required documentation is not a simple one and there are a lot of issues to consider if the process is to be improved. And, I’m certain there are barriers and roadblocks for both entities preventing the achievement of higher percentages of submission of appropriate medical record documentation. But, I think we need to do better. How can we know how much documentation is enough documentation if we can’t gather enough documentation to study it?

The GAO article can be found here: https://www.gao.gov/assets/700/697981.pdf

The post How well are Statutory Documentation Requirements Decreasing CMS Program Risks? appeared first on PayerWatch.

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

Reproduced with permission of ICD10 Monitor

Denise Wilson MS, RN, RRT
Vice President of Clinical Audit and Appeal Services, Intersect Healthcare

Higher overturn rates noted when the appeal is filed outside of the payer’s internal appeal process. 

I’d like to share some information gained from appealing over 2,000 clinical validation denials for sepsis in the state of New York since the time of the release of the Sepsis-3 criteria in February 2016.

Many of the commercial and managed care payer denials we have received from our clients in New York have been issued by a third-party contractor, not by the payer themselves. Most of these third-party contractors are using, but not specifically quoting or citing, Sepsis-3 criteria in their audits.

The denial language almost always includes some phrasing about the lack of evidence of acute organ dysfunction or end-organ compromise. Occasionally, the third-party contractors will mention Sequential Organ Failure Assessment (SOFA) scores, but without any specific citing of the SOFA criteria.

So, when UnitedHealthcare (UHC) stated in October 2018 that it would be using Sepsis-3 criteria in its audits, I viewed it as just a formalization of the process they were already following. Then, on Jan. 15, the Healthcare Association of New York (HANY) told providers that New York would not use the UnitedHealthcare  Sepsis-3 criteria when reviewing claims to validate sepsis for payment. And the Greater New York Healthcare Association (GNYHA) confirmed that UHC stated that it would not implement Sepsis-3 criteria in the state of New York. It will be interesting to see how or if UHC’s auditing process changes after the response from the Greater New York Healthcare Association.

New York is a state that allows for clinical validation denials to be taken to external review once the commercial payer’s internal appeal process has been exhausted. Some states view clinical validation denials as payment disputes and allow for external review when the medical necessity of the services provided is in question, but not for actual payment disputes. We have experienced higher overturn rates when the appeal is filed outside of the payer’s internal appeal process, but not all states allow that.

We have found that having the opportunity to appeal to an IRE (Independent Review Entity, or agency) in the state of New York has contributed to a higher success rate of achieving overturned denials than for providers in other states that do not offer the opportunity to appeal to an external agency. If your state allows clinical validation denials to be appealed to an IRE, you should be taking advantage of that.

From our experience, when reviewing sepsis denials, the IREs are looking for consistent physician documentation in the medical record establishing the clinical evidence by which sepsis was diagnosed and treated. The IREs are not quoting Sepsis-3 criteria per se, but they are looking for organ dysfunction caused by a dysregulated host response to infection. In order to pass muster for the IREs, there should be documentation that the conditions identified in the medical record required continuous treatment, evaluation, and monitoring, and that the identified abnormal clinical values were attributed to the sepsis by the physicians caring for the patient. The abnormal clinical values don’t necessarily have to be limited to those described in the SOFA criteria, as long as the abnormal values are indicative of organ dysfunction. The physician’s documentation has to make that connection that the abnormal clinical values that support the organ dysfunction are a result of the sepsis. A clearly documented correlation between organ dysfunction and sepsis will very often result in an overturn of a clinical validation sepsis denial.

At least that has been our experience.

The post Appealing Clinical Validation Denials in the Era of Sepsis-3 appeared first on PayerWatch.

When reviewing an NCD, LCD, or CPB, pay particular attention to the sections that spell out the following:

• Coverage Indications
• Limitations and/or Medical Necessity of the Service
• Documentation Required for Payment of Services
• Covered ICD-9
• Billing Codes

The guideline may require supporting lab results, radiology reports, therapy records or a listing of current medications. These may need to be obtained from the files of another provider. When developing a template for a particular medical or surgical procedure, it’s easy to include the list of medical necessity requirements and required documentation in the template. In fact, these can be included in such a way that the appeal writer can use them as a checklist of sorts to argue that all required documentation is present in the medical record. In some instances, you can give a reason for why particular documentation is not included. For example, explaining why a patient who was unable to tolerate a certain drug regimen prior to advising him to move ahead with surgery. In this way the appeal writer does not have to research the payment policies or guidelines for surgeries or procedures. Rather they can simply compare those guidelines embedded in the appeal letter to the documentation in the medical record. Even if the denial or the given reason for the pre-payment audit is one specific issue—such as a trial of conservative care before surgery—including all of the payment requirements in the appeal letter template allows the appeal writer to assure the auditor that all requirements are met. That helps prevent a second denial for a different payment requirement.

The final piece of the appeal is to build the roadmap between payment requirements and the medical record. Make it as easy as possible for the auditor or reviewer to rule in your favor by citing specific page numbers of the medical record where the required documentation can be found. If the appeal writer can point the reviewer to the exact documentation in the medical record that supports the medical necessity of services provided, the reviewer will have a much easier time finding the supporting documentation. Conversely, the reviewer will have a much harder time finding a reason to deny the appeal. Creating the road map can be accomplished in a variety of ways, but in its simplest form, a road map is a citation of the name of the document and the page number of the medical record where the documentation referenced in the appeal argument can be found.

How are you incorporating payer payment guidelines in your appeal letter templates?

The post Why You Should Include Payer Payment Guidelines in Appeal Templates appeared first on PayerWatch.

Using an appeal letter template allows for increased efficiency in performing appeal work. The research of each insurance carrier’s payment policy is completed once at the time the template is developed. By tailoring the appeal argument to each specific issue that the payer has identified as the reason for the denial, it eliminates the need to write each appeal from scratch.

One of the first tasks that must be completed when creating an appeal template is to understand the insurance payer’s language. It’s important to understand the payer’s definitions of “medical necessity” and “reasonable and necessary.” These are the basis for the vast majority of reasons to deny. It’s equally important to include the payer-specific language for medical necessity in the appeal template. This allows the appeal writer to use the template to help determine whether the medical record meets the payer’s requirements for documentation of payable services.

Remember, the appeal writer does not have to research the payer definitions in order to use the payer’s language in the argument as it is already supplied in the template. Most payers use similar language to define medical necessity of services. Using each payer’s own language in the payer-specific template ensures the appeal arguments are precise in refuting the payer’s decision to deny payment.

When defining medical necessity, most payers base their payment policies on services that are provided according to the standard of care in the medical community. This standard of care is generally defined as the incorporation of evidence-based medicine and guidelines into appropriate medical care. It’s beneficial if the research for appropriate evidence based guidelines that support the standard of care is done in advance. It’s even fine if the research is done at the time of writing the first appeal letter for a given issue and incorporating it into a template. This allows all appeal writers the ability to take advantage of the templated research.

The best research evidence can come in many forms. These can include peer-reviewed, published medical journal articles, a review of available studies on a particular topic, evidence-based consensus statements, expert opinions of health care professionals or guidelines from nationally recognized health care organizations. The Institute of Medicine defines clinical practice guidelines as such:

“Clinical Practice Guidelines are statements that include recommendations intended to optimize patient care. They are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”

From the Institute of Medicine’s, “Clinical Practice Guidelines We Can Trust” http://www.nap.edu/catalog/13058/clinical-practice-guidelines-we-can-trust

Most payers will define or provide examples of what types of published literature or research they consider acceptable as supporting the standard of care in the medical community. That doesn’t necessarily prevent the use of literature outside of the payer’s “list” to argue medical necessity. Yet, any clinical practice guideline or evidence-based medicine guideline needs to stand the test of whether it is accepted as the standard of care in the medical community.

One model often copied by commercial payers is Medicare. This is what they say about acceptable standards of care in the medical community:

“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.”

https://www.cms.gov/Rulings/downloads/hcfar951.pdf

So, how are you incorporating evidence based medicine guidelines into your appeal letter templates?

The post The Use of Evidence Based Medicine in Appeal Letter Templates appeared first on PayerWatch.

Where it Comes From

Limitation on Liability comes from the Social Security Act § SEC. 1879. [42 U.S.C. 1395pp] to be exact. http://www.ssa.gov/OP_Home/ssact/title18/1879.htm. Remember, all things Medicare and Medicaid were born through the Social Security Act, and are formed through the Code of Federal Regulations, and interpreted by CMS. When you read the Limitation on Liability of Beneficiary Where Medicare Claims Are Disallowed, which is the full title, you see the phrase “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,” multiple times. This is the essence of the Limitation on Liability portion of the Social Security Act as it relates to denial of payment for services under Medicare.

Medicare considers that a provider should know when payment is made for certain services 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 [the “old” name for CMS] notices

(2) Federal Register publications

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

In short, CMS has supplied the provider with all kinds of information on what services are covered and what services are not covered. For example, custodial care is defined as “Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom…includ[ing] care that most people do themselves, like using eye drops,” is not covered.

Knowing this, a provider should know better than to bill for services that are not covered and expect payment. However, did you see #3 above? There’s our favorite phrase, “considered acceptable standards of practice by the local medical community”. If your surgeons are amputating fingers for paper cuts, don’t expect to get paid for that. However, if you have provided care to a person based on the acceptable standards of care in the medical community and the documentation in the medical record supports that, you have a very strong argument for payment.

How are you using Limitation on Liability to win appeals?

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Evidence based guidelines support the standards of care in the medical community. These guidelines describe the reasons for admission of patients presenting with chest pain, and they don’t change from patient to patient. While the standards of care may change over time, which is one reason why your library is never finished, the standards of care do not change based on the patient or the payer.

One of the first lessons I learned as an appeal writer was using an appeal letter template would save me a lot of time, effort and frustration. As I watched the pile of denials and medical records on my desk grow at a rapid rate, I knew a well-written appeals template would help me do more and win more appeals. I’m not talking about a one-page Word document that has a place for a header, a salutation, and a closer. I’m talking about a full fledged template that includes fields for all vital patient information, required whenever you file an appeal.

Further, an effective appeal template includes:

• The patient narrative
• Arguments around medical necessity
• Coding criteria
• Regulatory or payment citations
• Any other information that leads to a compelling argument for payment.

This leads to a decision in our favor.

Creating appeal letter templates is not an easy task. It is time consuming and requires research and experience in appeal writing. Creating an appeal letter template library is work that has a beginning, but never an end. Templates must be reviewed, updated, recreated, appended and adjusted to maintain the relevance and effectiveness of the arguments. Yet, having an appeal letter template library is so worth it. The time and effort you can save in the work of appeal writing is invaluable.

Begin with your most frequently denied issues. These are typically those short-stay inpatient admissions that enter through the ED: chest pain, syncope, heart failure, TIA. What arguments have been successful in overturning these denials? Start with a letter that was successful and go from there. Do the research to determine the standard of care in the community and include that in your template. Just use the three or four sentences from evidence based medicine that support the medical necessity of admission or procedure. Do that for every new issue that comes across your desk and eventually you will have built a library of resources.

An appeal template library can transform your work from overwhelming to winning. How have you approached the development of your appeal letter template library?

The post Cut your Workload and Win More Appeals with Appeal Letter Templates appeared first on PayerWatch.

As a clinician, for me, the answer is the knowledge of the area of medicine concerning the denial. I know I am most comfortable and happiest when a denial in my queue of assigned appeal work involves a cardiac or pulmonary diagnosis which mirrors my clinical background.

How Appeal Letter Templates Help You Win

Now, granted, a well designed appeal letter template will help guide the appeal writer to a very strong argument for medical necessity around any diagnosis or procedure by including standards of medical care. An appeal letter template can equip a writer to write a very strong argument for the need for major joint replacement surgery by comparing the required documentation elements already present in the appeal template to the documentation in the medical record. I am also not proposing that you must always match up the clinical issue with a clinician who has experience in that area. That would be impossible for most organizations. Who has that many appeal writers on hand?

Building a Winning Team

There is no substitute for actual clinical experience. I find that I can picture those cardiac and pulmonary patients whose services were denied payment because I have actually cared for similar patients in the past. As I read their histories and physicals, my mind begins to formulate how sick they are, what their needs and potential problems might be and how long it might take to resolve their current illness.

What about the other two areas of the triad? A well written appeal argument does no one any good if it doesn’t get to the payer on time, at the correct address and accompanied by appropriate and required information. Having an individual on your team who has intimate knowledge of the payers and their appeal, external review and dispute resolution processes is critical. That individual should have exceptional organizational skills as well as a winning disposition to create a solid and mutually respectful relationship between the payer and the provider.

The Medical Record

Finally, the medical record itself is a very important piece of the appeal process. Very often the response to the question posed at the start of this blog is that familiarity with the medical record is very important in appeal work. Familiarity with the structure of the medical record certainly makes for quick and efficient work in appeal writing. And, it doesn’t hurt if a writer becomes familiar enough with a care provider’s scribbling to actually make out what was written in the record. Is the provider producing a medical record that is “auditor friendly” and thus, “appeal writer friendly”? Is it complete, well organized, tabbed, page numbered, without pages and pages of redundant information? A poorly produced medical record will increase frustrations while decreasing efficiency and effectiveness of the appeal argument.

So, how would you answer the question posed above? How is your appeal team organized? Are there other important areas that I haven’t considered here?

The post The Triad of the Appeals Team appeared first on PayerWatch.

Think of the appeal process as a conversation between provider and payer. Maybe not the easiest and smoothest of conversations, to be sure, but it’s what we have to work with today.

1. The payer reviews your payments and documentation and lets you know what they don’t like about it in the form of denied payment. If you’re really lucky, they’ll even give you a bit of explanation of why they don’t like it.
2. The provider then appeals it with arguments on why the patient encounter should be reimbursed as billed.
3. Next, the payer let’s you know they don’t agree, and so forth.

If you pay close attention to this conversation you can learn a lot about how to structure your arguments in the future.

Using Payer Language to Win Appeals

One very important element of this conversation is the practice of speaking the same language as the payer. I am referring to when the payer claims payment will not be made because the services provided were not reasonable or medically necessary. The appeal language should include an argument that the services provided were indeed reasonable and medically necessary and then expalining why.

A payer may state the knee replacement surgery was not medically necessary because there was no reasonable attempt at conservative therapies prior to the surgery. The appeal language should include an argument how there was indeed an attempt at conservative therapies and then show where those attempts are documented and why they failed.

Using the payer denial language in your appeal makes it very clear to the reader which reasons for denial are being refuted. Of course, you want to refute each and every reason for denial with clear and specific detail. So, use their own denial language to structure your appeal arguments and you’ll find the conversation easier to manage and more successful for the provider.

What elements of payer language are you struggling to understand?

The post Speaking the Same Language as the Payer appeared first on PayerWatch.

I often wonder how easy it would be for Medicare to go after that issue alone. Typically, authentication of medical record entries are not the subject of focused reviews, but are identified during audits of other issues. I recently read a publication from CMS regarding CERT reviews for the medical necessity of AICD placements and was very surprised to learn that the vast majority of denials were for missing physicians’ signatures and other issues lumped into record keeping. It doesn’t matter how well the medical necessity was documented of the need for the AICD if the physician didn’t sign his procedure note or his signature was illegible it was an automatic denial. Talk about easy money.

“The CERT study found that approximately 85 percent of the improper payments were due to insufficient documentation, and this included lack of:

1. Physician’s signature on the procedure note;
2. Signature log or attestation for cases in which the physician’s signature was illegible;
3. Electronic record protocol/policy that documents the process for electronic signatures, if applicable;
4. Hospital records;
5. Records for the specified date of service;
6. Records that support the clinical indication for the procedure; or
7. Records to support that the beneficiary was enrolled in a clinical study/trial.

In the CERT study, medical necessity errors caused approximately 12 percent of the improper payments.”

Besides internal processes for ensuring appropriate authentication of medical record entries, I think we also have to consider whether our electronic medical records and hybrid (part paper, part electronic) medical records are playing a role in these denials.

What does your medical record look like if you print it out and send it to a reviewer? What does it look like if you send the record electronically? Is it clear to the reviewer that the physician did indeed sign the procedure note? It’s too easy for the payer to deny payment for a such a simple and correctable mistake as a missing physician signature.

The post Physician Signatures Matter appeared first on PayerWatch.