1. DRG Denials, Medical Necessity and Payer Behaviors
Kim Alexander, RN, BSN, RAC and Appeals Coordinator
Stephanie Brown, RN Revenue Recovery Specialist
UK Healthcare

2. Faculty Disclosure
Kim Alexander and Stephanie Brown have not had any relevant financial relationships during the past 12 months.

3. Educational Need/Practice Gap
Gap = Importance of documentation specifics related to each patient encounter Need = Volume of denials, and ability to focus on actual deficits

4. Objectives
Upon completion of this educational activity, you will be able to:
Distinguish the need for clear, concise documentation from MD for quality of care coordination.
Explain the connection of documentation and reimbursements.
Identify ways to improve documentation for defense of denials.

5. Expected Outcome
What is the desired change/result in practice resulting from this educational intervention?
The physicians will be able to translate into practice, the value of the snapshot only they can provide.

6. Health Insurance is a for profit business
The primary function of multi-billion dollar insurance companies is to make more billions for themselves and their investors.
Functions are outsourced, systems are not synchronized
Difficult to determine why claims not paid

7. Medical Necessity and Beyond

8. Denials Task Force *Total Billed Charges, per remit posted in AEOS

9. CC DENIALS 1/1/2016-6/30/2017 **EXPECTED PAYMENT, INPT & OUTPT
TYPE
Count of Acct No
Sum of Payer Amt Due
Authorization
4434
$6,498,986.68
Billing Error
3906
$5,339,340.59
Coding
595
$490,857.29
Documentation
612
$1,079,300.24
Max Benefits
159
$105,287.45
MD Credentialing 3
$6,990.75
Medical Necessity
404
$1,038,458.45
Other
1908
$1,588,288.50
Timely Filing
242
$243,444.60
Grand Total
12263
$16,390,954.55

10. Medical Necessity Solutions: Why is it important now?
Denial management best practice: front-end avoidance
All payors have some type of medical necessity denials
Lack of pre-authorization: the #1 patient access-related denial
More federal dollars focused on compliance
Outpatient growth will continue
Future RAC audits will be auditing compliance with regional LCDs and NCDs
Advanced Beneficiary Notice (ABN)

11. Relevant Definitions-why all the fuss?

12. Goal of Audits-Save Money

13. Proper Medical Necessity tools and processes ensure revenue integrity
Mitigating compliance risks
Improve staff efficiency
Decrease write-offs
Reduce future post- payment reviews and medical necessity audits
Reduce the need for ABNs
Ensure ABN process only takes minutes

14. WIIFM What’s In It For Me?
Quality Measures—SOI(Severity of Illness) and ROM(Risk of Mortality)
Value Based Modifier (VBM)
Medicare Physician Compare, HealthGrades.com, and more
Potential Employment Metrics/Payer Preferences
Medicare Spending per Beneficiary
Present on admission (POA)

15. MYTHS ABN adds too much time No compliance risks
Easier to work the denials on the back-end
Can still manually manage payor requirements
Small claims do not impact the bottom line

16. Denials Best Practice
Prevention with Comprehensive Documentation NOT Denials Management with Appeals
According to the AHA, hospitals report that nearly three-fourths of appeals are sitting in the appeals process

17. Clinical – Operational-Financial Linkages

18. Process of Denials Management

19. The PROCESS Why was it denied? Can it be appealed?
Did we make a mistake?
Appeal
PREVENT

20. Why was it denied? Incomplete submission of records
Incomplete signatures or consents
Incomplete documentation of medical necessity
Drugs given without a current order
Dosage or procedure not documented
Non-specific coding
Payer/Medicare guidelines not met
Required authorizations not obtained

21. Can it be appealed? Do we have a complete record?
Is the documentation supportive of medical necessity?
Does the treatment meet the payer’s guidelines?
Were appropriate authorizations obtained?
Within the timeframe allowed for appeals?

22. Did we make a mistake?
Is billing correct for the procedure/care provided?
Is the status (inpatient or outpatient) correct and matching authorizations?
Did we send the correct records with an audit request?
Did we send any requested information timely?

23. The APPEAL
Complete identifying information (member, hospital, dates, issues, etc)
REASON we want this case reviewed and expected outcome.
Supporting documentation
excerpts from the medical record to support
the argument, applicable guidelines, unusual circumstances of the specific case, medical review literature or clinical study information any other information that may apply

24. How can we prevent similar denials in the future?
PREVENTION
How can we prevent similar denials in the future?
Identify the issue and possible trends
Address trends and develop action plan
Implement a corrective process
Review for outcomes
“Taking care of denials can be like swatting flies, when you should be shutting a window somewhere.” 

25. A TEAM Approach Develop a noteform for dictations
Establish an internal audit process (example for Total joints and Cataracts)
To review the documents before the patient is placed on the surgery schedule
Provide feedback about documentation to the surgeons
Track the authorizations, and mitigate future denials

26. COMPLETE vs INCOMPLETE Documentation

27. Medicare Guideline for Cataracts
Decreased visual function due to the cataract
1. Decreased ability to carry out ADL’s
2. Best corrected visual acuity of 20/50 or worse OR with additional testing shows decrease by 2 lines
3. The patient determines they can no longer function
4. Other causes of vision loss are ruled out
5. Significant improvement is expected
6. Patient education re. risks and benefits
7. Appropriate evaluation including comprehensive exam and ophthalmic biometry

32. Cataract Documentation Template for ADL’s

33. Orthopaedic Template- Joint Arthroplasty
Used to provide the guideline required elements of history and treatments prior to surgery. The form is available in AEHR

42. Intent vs Actual Documentation

43. Best Practice What do you want to convey?
Many people- other than doctors- may access the record.
When in doubt, specific is better than general.

44. A Partnership Templates based on Medicare Guidelines (LCDs and NCDs)
Increased contact from UM in real time to ensure appropriate authorizations
Be aware of the policies and guidelines that are available for public knowledge
Utilize every opportunity to ensure that medical necessity it met or appealed on the front end

45. Project: Prevention Total joint project Cataract project
Pacemaker audits
Watchman Devices
LESI procedures
Cardiac Rehab
PET Scan
IAuth implementation

47. Sources
Clinical-operational-financial linkage-Charleeda Redman, Optum Forum 2015
Relevant definitions
WIIFM-John Zelem, MD, FACS, VP, Compliance and physician Engagement, Optum Forum 2015
Goal of audits-Save Money-John Hall, MD, CCO, Optum Forum 2015
‘Taking care of flies…..” Krishna Ramachandran, CO, Downers Grove, DMG.