ACPA Members Blog

Steven Meyerson, MD, CHCQM-PHYADV, Member of the ACPA Board of Directors
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The views and opinions expressed herein are those of the author and do not necessarily reflect those of the American College of Physician Advisors.

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Fighting Inappropriate Medicare Advantage Denials

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The discussion groups are ablaze with talk about the inappropriate denials issued by the Medicare Advantage plans. Common denials include an admission that was either pre-certified or concurrently authorized and then denied after discharge when "the medical record does not support inpatient admission," and denials of admissions that surpassed two midnights because "the patient did not meet inpatient criteria" (referring to InterQual or MCG criteria sets.) There are also an increasing number of denials of payment for second admissions that occur within 30 days of an index admission, citing the plan’s readmission policy.

Through the work of several persistent discussion group members, a process to escalate these inappropriate denials has been developed and has been remarkably successful, at least so far. Despite these successes by individual hospitals, the American Hospital Association needs to step up and defend the rights of hospitals to be paid for the medically necessary care they provide to patients and take this issue to CMS and Congress.

So, how should you handle a Medicare Advantage denial that appears inappropriate?

First, clearly outline the reason for the denial. Was it an issue of the medical necessity for the service itself or an admission status issue?

What information was conveyed to the insurer to obtain authorization? Was that information accurate? Physicians will occasionally "stretch the truth" to obtain approval. While the hospital should not be held financially liable for a physician’s action, that is one of those things that we have all come to accept as part of the game.

What does your contact with the plan say about the issue at hand? If your contact allows retrospective denials after a concurrent authorization, you have no grounds to complain about the process, although you can appeal the denial.

Does the plan have published policies and procedures regarding the issue? Some plans state they follow Medicare guidelines, in which case the Two Midnight Rule would apply. Remember that CMS only requires Medicare Advantage plan patients to get care equivalent or better than traditional Medicare; to CMS, how the plan pays (or doesn’t pay) providers is a contractual issue outside their realm.

In the case of level of care denials, was the hospital care truly medically necessary for all days in question? Do not defend an appropriate denial just on principal.

In the case of a readmission denial, was the second admission related to the index admission and was it avoidable because of an omission by the hospital? Look at the plan’s readmission policy for pertinent definitions. A hospital should not be responsible for a repeat exacerbation of heart failure after 25 days if the patient can only afford to eat fast food and ramen noodles.

Once you decide to proceed, follow the plan’s appeal process. If your appeal is telephonic, get names, credentials, and numbers and ask for a written denial letter. Save all correspondence.

If your appeal is denied, and you feel that the denial was improper, it is then time to go to CMS.

In your correspondence to CMS, outline the issue in detail. Briefly review the case and the plan’s denial. State pertinent plan polices and regulations. Do not include PHI unless requested by CMS. If there is a claim number, that can be included. Explain why you feel the plan violated their own policies or CMS policy.

Request a reply, but do not demand a specific action. Attach a copy of the denial letter from the plan.

Send a copy of your letter to the plan appeal department. They need to know that you are not taking their shenanigans siting down.

While CMS does have a general mailbox at questions.CMS.gov that can be used for these issues, the collective work of discussion group users has led to a list of several CMS contacts for specific plans. Use these contacts wisely; we do not want to jeopardize the hard work of those who sought them out. And finally, please share your successes and failures either on the ACPA blog or a discussion group. We can all learn from each other. And finally, I present the list:

Humana:

Uvonda Meinholdt 
Health Insurance Specialist 
Kansas City Regional Office 
Phone: 816-426-6544 
FAX:  443-380-6020 
Uvonda.Meinholdt@cms.hhs.gov

UHC:

Nicole Edwards

Nicole.edwards@cms.hhs.gov 

 

Blue Cross and Anthem:

Anne McMillan

Health Insurance Specialist

Chicago Regional Office

Phone: 312-353-1668

Anne.McMillan@cms.hhs.gov

 

Coventry and Aetna:

Don Marek

Health Insurance Specialist

Denver Regional Office

Phone: 303-844-2646

Don.Marek@cms.hhs.gov

 

General CMS Contact:

Melanie Xiao 

Health Insurance Specialist

Medicare Advantage Branch

Division of Medicare Health Plans Operations

Centers for Medicare & Medicaid Services

CMS San Francisco Regional Office

90 7th Street, 5-300 (5W)

San Francisco, CA 94103-6708

Phone: 415-744-3613

FAX:    443-380-6371

melanie.xiao@cms.hhs.gov

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Comments

  • I would like to add to Dr. Hirsch's comments about the MAPs as one of the front line fighters in this battle. One suggestion is to bundle groups of denials (inpatient concurrent authorization for care subsequently denied, DRG validation with denial for diagnosis clearly defined in the record, etc.). When you escalate to CMS let them know that it is not an isolated event but a series of egregious activity. Emphasize that the effect can be deleterious to the beneficiary for issue like when a case is concurrently reviewed with authorization as inpatient then the facility has every right to expect payment and therefore could hold the beneficiary liable. With the DRG validation audits raise the continued concern as to whether or not the plans are reporting to CMS the denied diagnoses to reduce the RADV on which they are paid. These types of complaints led to exposing the plans to RAC audits so that they can now have of taste of what it is like to be on the receiving end of audit findings. In South Carolina we have the support of the South Carolina Hospital Association, State Department of Insurance and are reaching out to the national Association of Insurance Commissioners to continue to escalate the fight to hold these plans to reasonable rules so that we can all play the same game by the same rules but hopefully to have reasonable rules. We have won some battles but the war continues. A task force from the Governmental Affairs Committee with ACPA has also had some initial discussions. The next big area for me is the 30 day readmission policies with payers denying even though the readmission was not a direct result of anything our facility could have done. Where we are is the result of work by a lot of individuals who have been willing to share information to help each other. I am proud of the efforts from all involved and amazed at the willingness to share vital information that helps each of us accomplish our jobs and increasingly holds these plans accountable. The regulatory bodies are being forced to take an active role as evidenced by the list of contacts above. I want to thank Dr. Hirsch for his recognition of my contribution to these efforts as one of many and look forward to the opportunity to have further discussions at various upcoming meetings with anyone willing to listen. The bottom line is that we can make a change particularly if we work as a group to bring these activities to the light of day so jump on board and add your talents to the efforts.
    2/9/2016 9:25:53 AM
    • @R. Phillip Baker: This is a topic I feel we have only peeled the first layer of the onion on. The first method to fight MA plan shenanigans is to involve the Physician Advisor in contract negotiations with the payers. Typically finance departments do the negotiating and are most concerned with the dollars. The PA can attempt to gain a fair appeal process and mandate adherence to CMS policy with regard to readmissions, etc. Secondly these MA plans are not particularly adept at making it simple to have grievances heard. They must be pursued via the CMS representative posted in Dr. Hirsch's article. After filing a CMS grievance, you will get a call back promptly! More to follow! Howie Stein
      2/9/2016 2:14:41 PM
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