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

2. 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

3. 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

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

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

6. 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

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

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

9. 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 CareSource is committed to providing network notification via clear communication with provider field representatives regularly

10. 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

11. Who has the first question?

12. Thank you Deborah Donofrio, RN ddonofrio@humanarc.com
(216) X1436