Denial Strategies for Dealing with Ohio Payers Deborah Donofrio, RN Human Arc Clinical Specialist May 19, 2017

Bio Attended Fairview General Hospital School of Nursing and Cleveland State University Twenty years of clinical nursing experience including orthopedics, general surgery, surgical intensive care, psych, emergency care and triage. Have worked in the managed care arena since 1997 with positions in utilization review/management, discharge planning, case management, Quality Assurance and Hedis with multiple payers including Anthem, Medical Mutual and Kaiser Permanente. Been with Human Arc, a Centauri Health Solutions Company, since 2009

Topics General Trends for 2017 Prior Authorization Post Payment Audits Behavioral Health Increased Claim Denials seen in following areas Specific Payor Updates/Trends Q & A

General Trends for 2017 Legislation attempts to repeal Affordable Care Act Value Based Care Models Consumerism Pharmacy Trends (including pricing, drug access, and regulation)

Prior Authorization Expanding in 2017 More services requiring Challenge to current overextended staff

Post Payment Audits Continue at a rapid pace Recoupment even with presence of Prior Authorization Short Appeal Timelines Measure of Performance Readmissions Quality Scores Hospital acquired conditions

Behavioral Health Opioid Addiction Epidemic Documentation of requirements for severity of illness DSM 5 Diagnosis Patient plan of active psychiatric treatment

Increased Claim Denial Areas National Drug Code submission Z code identifiers IV Therapy and wastage

Payer Updates/Trends Anthem AIM Specialty Health – Medical Necessity reviews for Vascular ultrasound procedures 93925 DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY 93926 DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY 93930 DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY 93931 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY Caresource Claim processing and appeal determinations delays – OHA addressed New policies and procedures can be reviewed at www.caresource.com. CareSource is committed to providing network notification via clear communication with provider field representatives regularly

CMS Updates New Medicare RAC Contracts Performant Recovery Inc. Awarded contract for Region One (Ohio in this region) in October Perform post payment review of Part A & B Medicare fee for service claims for all provider types with the exception of home health/hospice and DME suppliers RAC activity was set to begin before the end of March 2017 ADR’s RAC Approved Issues for Facility Claims Complex Inpatient Hospital MS DRG Coding Validation Complex Medical Necessity Bariatric Surgery Automated Cataract Surgery Complex Medical Necessity Cardiac PET Scans Herceptin (J9355) *Multi Dose Vial Wastage billed with JW modifier Lexiscan (Regadenoson) billed with greater than four units Automated Inpatient Psych billed without source of admission equal to “D” Sacral Neurostimulation

Who has the first question?

Thank you Deborah Donofrio, RN ddonofrio@humanarc.com (216) 426-3535 X1436