Effective Appeals 2.0
Researching the Ultimate Appeal Letter
Call in Phone Number: 712-432-0075
Access Number: 866886
Part...
Effective Appeals 2.0
The Next IHI Appeal Education
Event
Using Advanced Document
Management Techniques to Create
the Ulti...
Effective Appeals 2.0
Researching the Ultimate Appeal
Letter
3
Copyright 2010 INTERSECT HEALTHCARE, INC.
Denise Wilson MS,...
Introductions
 Denise Wilson MS, RN, RRT
 Director of Audit and Appeal Services at Intersect
Healthcare, Inc.
 28 years...
Introductions
 Intersect Healthcare, Inc.
 One of the nation's leading providers of Payor
Compliance and Audit and Denia...
Appeal Education Offerings
 Online Education - $550 per facility includes:
 Fifteen MS-DRG Appeal Templates from IHI App...
Appeal Support Services
 AppealMasters Outsourcing – from $250 per
case
 DRG Validation and Medical Necessity Experts
 ...
Learning Objectives
 Research regulations to support your winning
argument.
 Research payment and reimbursement
guidelin...
Building the Foundation for
Appeal9
Copyright 2010 INTERSECT HEALTHCARE, INC.
Start with the Decision Letter (Following al...
Building the Foundation for
Appeal
Copyright 2010 INTERSECT HEALTHCARE, INC.
10
Review the Reason for Denial
Excerpt from ...
Building the Foundation for
Appeal
ICD-9-CM Official Guidelines for Coding and
Reporting
 These guidelines are included o...
Researching CMS Regulations
 CMS Internet Only Manuals (IOM)
 http://www.cms.gov/Manuals/IOM/list.asp
 100-02 Medicare ...
Researching CMS Regulations
 CMS Internet Only Manuals (IOM)
 http://www.cms.gov/Manuals/IOM/list.asp
 100-02 Medicare ...
Researching CMS Regulations
 CMS Internet Only Manuals (IOM)
 http://www.cms.gov/Manuals/IOM/list.asp
 100-03 Medicare ...
Researching CMS Regulations
 CMS Internet Only Manuals (IOM)
 http://www.cms.gov/Manuals/IOM/list.asp
 100-04 Medicare ...
Researching CFR Regulations
 Code of Federal Regulations (CFR); 42
CFR 400 and following
 Describes the Appeal Process i...
Researching CMS Regulations
 National Coverage Determinations
 Published by CMS
 Applies to all CMS providers/beneficia...
Researching CMS Regulations
 Local Coverage Determinations
 Developed and published by MACs/FIs
 Applies to providers/b...
Researching CMS Regulations
 Local Coverage Determinations
 http://www.cms.gov/MCD/overview.asp
 Local Coverage
 LCDs
...
Researching CMS Regulations
 ICD-9-CM Coding Manual
 ICD-9-CM Addendums
(The National Center for Health Statistics
(NCHS...
Researching CMS Regulations
 RAC SOW p. 18
 “When making coverage and coding determinations, if
no written Medicare poli...
Researching SSA Regulations
Limitation on Liability § 1879 of the Act
Excerpt from Focused Review Denial (NGS)
22
Copyrigh...
Researching SSA Regulations
 Limitation on Liability; Social Security Act § SEC. 1879
 Sec. 1879. [42 U.S.C. 1395pp] (a)...
Researching CFR Regulations
 Determining Limitation on Liability (42 C.F.R. § 411.406)
(a) Basic rule. A provider, practi...
Researching HCFA (CMS)
Rulings
 Determining “acceptable standards of practice by the
local medical community” (HCFA Rulin...
Researching HCFA (CMS)
Rulings
 Determining “acceptable standards of practice by the
local medical community” (HCFA Rulin...
Researching Acceptable
Standards of Practice
Copyright 2010 INTERSECT HEALTHCARE, INC.
27
LCD from Highmark Medicare Servi...
Researching Acceptable
Standards of Practice
Copyright 2010 INTERSECT HEALTHCARE, INC.
28
 NCD for Cardiac Pacemakers (20...
Researching Acceptable
Standards of Practice
Copyright 2010 INTERSECT HEALTHCARE, INC.
29
 Evidence Based Guidelines; Pos...
Researching Acceptable
Standards of Practice
Copyright 2010 INTERSECT HEALTHCARE, INC.
30
 Evidence Based Guidelines; Pos...
Researching RAC Issues
 RAC Demonstration Project
 http://www.cms.gov/RAC/02_ExpansionStrategy.asp
 RAC Websites (CGI)
...
Researching RAC Issues
 Region A DCS
 http://www.dcsrac.com/IssuesUnderReview.aspx
 Region B CGI
 http://racb.cgi.com/...
Links
 Social Security Act
 http://www.socialsecurity.gov/OP_Home/ssact/ssact-toc.htm
 ICD-9-CM Official Guidelines for...
Links
 ICD-9-CM
 http://www.cdc.gov/nchs/icd/icd9cm.htm
 Coding Clinics (AHA)
 http://www.ahacentraloffice.org/ahacent...
Links
 Determining Limitation on Liability (42 C.F.R. § 411.406)
 http://www.gpoaccess.gov/cfr/index.html
 Determining ...
Research Tips
 Start with the Decision Letter
 Follow all Leads
 Match the Regulation or Guideline Year to the
DOS
 De...
Thanks for attending!
Research! Research!
Research!
Download, Bookmark, Print,
Save, Store, File,
Organize, Share, Use -
A...
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Researching the ultimate appeal letter 2.0

  1. 1. Effective Appeals 2.0 Researching the Ultimate Appeal Letter Call in Phone Number: 712-432-0075 Access Number: 866886 Participant pho ne s are m ute d. Afte r dialing in, yo u willno t he ar so und untilthe co nfe re nce starts. Copyright 2010 INTERSECT HEALTHCARE, INC. 1
  2. 2. Effective Appeals 2.0 The Next IHI Appeal Education Event Using Advanced Document Management Techniques to Create the Ultimate Appeal Letter Brian McGraw, CEO Wednesday, November 17, 2010 1:00 PM ESTCopyright 2010 INTERSECT HEALTHCARE, INC. 2 Advanced Document Management Techniques to Create the Ultimate Appeal Letters (An Adobe Acrobat Workshop)
  3. 3. Effective Appeals 2.0 Researching the Ultimate Appeal Letter 3 Copyright 2010 INTERSECT HEALTHCARE, INC. Denise Wilson MS, RN, RRT Director Audit and Appeal Services We can take your appeals to a higher level. Ask me how!
  4. 4. Introductions  Denise Wilson MS, RN, RRT  Director of Audit and Appeal Services at Intersect Healthcare, Inc.  28 years of healthcare experience in staff, management, compliance, education, and denials and appeals positions  Personally managed several hundred Medicare appeals and presented dozens of cases at the Administrative Law Judge level with a 95% success rate Copyright 2010 INTERSECT HEALTHCARE, INC. 4
  5. 5. Introductions  Intersect Healthcare, Inc.  One of the nation's leading providers of Payor Compliance and Audit and Denial Management software for healthcare providers.  Offers a comprehensive combination of denial and audit software, appeal services and education.  www.intersecthealthcare.com Copyright 2010 INTERSECT HEALTHCARE, INC. 5
  6. 6. Appeal Education Offerings  Online Education - $550 per facility includes:  Fifteen MS-DRG Appeal Templates from IHI Appeal Library  Two hours of Dedicated Online Education with Appeals Staff with Denise Wilson  Case Appeal walkthrough with one actual case, using the IHI appeal template  On Site Education - $1,600 per facility includes:  All Intersect Healthcare Medical Necessity and Coding Appeal templates  Dedicated training program on researching and writing the Ultimate Appeal letters using the templates as your starting point  Designing and defining your facility RoadMap to the ALJ  Chart review, abstracting and document management techniques to highlight the most important issuesCopyright 2010 INTERSECT HEALTHCARE, INC. 6
  7. 7. Appeal Support Services  AppealMasters Outsourcing – from $250 per case  DRG Validation and Medical Necessity Experts  A dedicated network of Physicians, Appeal Nurses and P.A.’s  RAC through the QIC for one competitive case rate  ALJ Hearing preparation and execution services available  No minimums required  Full access to IHI Library, AppealMasters Reporting on Realtime Appeal Status, Wins and Results  Simplified referral process through the VERACITYTM portal  Guaranteed turnaround times  Root Cause tracking for all referred issues Copyright 2010 INTERSECT HEALTHCARE, INC. 7
  8. 8. Learning Objectives  Research regulations to support your winning argument.  Research payment and reimbursement guidelines.  Research evidence based clinical practice guidelines.  Incorporate research into appeal letter templates.  Drive your reviewers to a decision in your favor by building a road map for your case.  Become an ultimate appeals writer by following all the leads and doing the research. 8 Copyright 2010 INTERSECT HEALTHCARE, INC.
  9. 9. Building the Foundation for Appeal9 Copyright 2010 INTERSECT HEALTHCARE, INC. Start with the Decision Letter (Following all the Leads) Excerpt from a Review Results Letter (HDI) Download and save these sections of the SSA in your Appeals Documents library. http://www.socialsecurity.gov/OP_Home/ssact/ssact-toc.htm Title XVIII Health Insurance for the Aged and Disabled 
  10. 10. Building the Foundation for Appeal Copyright 2010 INTERSECT HEALTHCARE, INC. 10 Review the Reason for Denial Excerpt from a Review Results Letter (DCS) Download and save the ICD-9-CM Official Guidelines for Coding and Reporting for these claims dates of service in your Appeals Documents Library.  
  11. 11. Building the Foundation for Appeal ICD-9-CM Official Guidelines for Coding and Reporting  These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Co ding Clinic fo r ICD-9 -CM” published by the AHA.  Updated annually.  http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm Copyright 2010 INTERSECT HEALTHCARE, INC. 11
  12. 12. Researching CMS Regulations  CMS Internet Only Manuals (IOM)  http://www.cms.gov/Manuals/IOM/list.asp  100-02 Medicare Benefit Policy Manual Chapter 1 - Inpatient Hospital Services Covered Under Part A  10 - Covered Inpatient Hospital Services Covered Under Part A  Definition of Inpatient  Physician’s responsibility on deciding on Inpatient admissionCopyright 2010 INTERSECT HEALTHCARE, INC. 12
  13. 13. Researching CMS Regulations  CMS Internet Only Manuals (IOM)  http://www.cms.gov/Manuals/IOM/list.asp  100-02 Medicare Benefit Policy Manual Chapter 6 - Hospital Services Covered Under Part B  20.6 - Outpatient Observation Services  Definition of Observation Services  Coverage of Outpatient Observation Services Copyright 2010 INTERSECT HEALTHCARE, INC. 13
  14. 14. Researching CMS Regulations  CMS Internet Only Manuals (IOM)  http://www.cms.gov/Manuals/IOM/list.asp  100-03 Medicare National Coverage Determinations (NCD)  NCDs are easier to find through the Medicare Coverage Database (MCD) index  http://www.cms.gov/MCD/overview.asp Copyright 2010 INTERSECT HEALTHCARE, INC. 14
  15. 15. Researching CMS Regulations  CMS Internet Only Manuals (IOM)  http://www.cms.gov/Manuals/IOM/list.asp  100-04 Medicare Claims Processing Manual Chapter 29 - Appeals of Claims Decisions  240 - Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals  250 - Amount in Controversy Requirements; Aggregation of Claims for Appeal Copyright 2010 INTERSECT HEALTHCARE, INC. 15
  16. 16. Researching CFR Regulations  Code of Federal Regulations (CFR); 42 CFR 400 and following  Describes the Appeal Process including the Administrative Law Judge process  http://www.gpoaccess.gov/cfr/index.html Copyright 2010 INTERSECT HEALTHCARE, INC. 16
  17. 17. Researching CMS Regulations  National Coverage Determinations  Published by CMS  Applies to all CMS providers/beneficiaries  CMS Internet Only Manuals (IOM); 100-03 Medicare National Coverage Determinations (NCD)  http://www.cms.gov/MCD/overview.asp  National Coverage  National Coverage Determinations (NCDs):  Alphabetical Listing Copyright 2010 INTERSECT HEALTHCARE, INC. 17
  18. 18. Researching CMS Regulations  Local Coverage Determinations  Developed and published by MACs/FIs  Applies to providers/beneficiaries residing in the MAC/FI region  Not allowed to be more restrictive than CMS regulations  ALJs do not have to abide by LCD regulations  http://www.access.gpo.gov/nara/cfr/waisidx_08/42cfr405_08.ht ml Copyright 2010 INTERSECT HEALTHCARE, INC. 18
  19. 19. Researching CMS Regulations  Local Coverage Determinations  http://www.cms.gov/MCD/overview.asp  Local Coverage  LCDs  By Contractor  By State  Alphabetically Copyright 2010 INTERSECT HEALTHCARE, INC. 19
  20. 20. Researching CMS Regulations  ICD-9-CM Coding Manual  ICD-9-CM Addendums (The National Center for Health Statistics (NCHS) and CMS)  http://www.cdc.gov/nchs/icd/icd9cm.htm  Coding Clinics (AHA)  http://www.ahacentraloffice.org/ahacentraloffice/shtml/Products.shtml  CPT, CPT Assistant (AMA)  https://catalog.ama-assn.org/Catalog/cpt/cpt_home.jsp Copyright 2010 INTERSECT HEALTHCARE, INC. 20
  21. 21. Researching CMS Regulations  RAC SOW p. 18  “When making coverage and coding determinations, if no written Medicare policy, Medicare article, or Medicare-sanctioned coding guideline exists, the RAC shall not use automated review. Examples of Medicare-sanctioned coding guidelines include: CPT statements, CPT Assistant statements, and Coding Clinic statements.”  http://www.cms.hhs.gov/RAC/downloads/Final%20RAC %20SOW.pdf Copyright 2010 INTERSECT HEALTHCARE, INC. 21
  22. 22. Researching SSA Regulations Limitation on Liability § 1879 of the Act Excerpt from Focused Review Denial (NGS) 22 Copyright 2010 INTERSECT HEALTHCARE, INC.
  23. 23. Researching SSA Regulations  Limitation on Liability; Social Security Act § SEC. 1879  Sec. 1879. [42 U.S.C. 1395pp] (a) Where— (1) a determination is made that, by reason of section 1862(a)(1) or (9) or by reason of a coverage denial described in subsection (g), payment may not be made under part A or part B of this title for any expenses incurred for items or services furnished an individual by a provider of services…, and (2) …such 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, then to the extent permitted by this title, payment shall,…be made for such items or services … http://www.socialsecurity.gov/OP_Home/ssact/ssact-toc.htm Copyright 2010 INTERSECT HEALTHCARE, INC. 23
  24. 24. Researching CFR Regulations  Determining Limitation on Liability (42 C.F.R. § 411.406) (a) Basic rule. A provider, practitioner, or supplier that furnished services which constitute custodial care under Sec. 411.15(g) or that are not reasonable and necessary under Sec. 411.15(k) is considered to have known that the services were not covered if any one of the conditions specified in paragraphs (b) through (e) of this section is met. (e) Knowledge 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 notices… (2) Federal Register publications… (3) Its knowledge of what are considered acceptable standards of practice by the local medical community. http://www.gpoaccess.gov/cfr/index.html Copyright 2010 INTERSECT HEALTHCARE, INC. 24
  25. 25. Researching HCFA (CMS) Rulings  Determining “acceptable standards of practice by the local medical community” (HCFA Ruling 95-1)  V. ACCEPTABLE STANDARDS OF PRACTICE--APPLICATION In situations in which services or items furnished do not meet locally acceptable standards of practice, the provider, practitioner, or other supplier is considered to have known that Medicare payment for the services or items would be denied. Providers, practitioners, and other suppliers are always responsible for knowing locally acceptable standards of practice; their local licensure is premised on the assumption that they have such knowledge. Medicare payment to providers, practitioners, or other suppliers is premised on the presumption that they have such knowledge, as evidenced by their licensure. No other evidence of knowledge of local medical standards of practice is necessary. http://www.cms.hhs.gov/Rulings/CMSR/list.asp Copyright 2010 INTERSECT HEALTHCARE, INC. 25
  26. 26. Researching HCFA (CMS) Rulings  Determining “acceptable standards of practice by the local medical community” (HCFA Ruling 95-1) Co ntinue d…  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. Copyright 2010 INTERSECT HEALTHCARE, INC. 26
  27. 27. Researching Acceptable Standards of Practice Copyright 2010 INTERSECT HEALTHCARE, INC. 27 LCD from Highmark Medicare Services
  28. 28. Researching Acceptable Standards of Practice Copyright 2010 INTERSECT HEALTHCARE, INC. 28  NCD for Cardiac Pacemakers (20.8)  Second reconsideration for Cardiac Pacemakers (CAG-00063R2)  Decision Memo
  29. 29. Researching Acceptable Standards of Practice Copyright 2010 INTERSECT HEALTHCARE, INC. 29  Evidence Based Guidelines; Position Statements  Professional Associations  American College of Cardiology  http://www.cardiosource.org
  30. 30. Researching Acceptable Standards of Practice Copyright 2010 INTERSECT HEALTHCARE, INC. 30  Evidence Based Guidelines; Position Statements  Professional Associations  American Thoracic Society  http://www.thoracic.org/statements/index.php
  31. 31. Researching RAC Issues  RAC Demonstration Project  http://www.cms.gov/RAC/02_ExpansionStrategy.asp  RAC Websites (CGI) Copyright 2010 INTERSECT HEALTHCARE, INC. 31
  32. 32. Researching RAC Issues  Region A DCS  http://www.dcsrac.com/IssuesUnderReview.aspx  Region B CGI  http://racb.cgi.com/Issues.aspx  Region C Connolly  http://www.connollyhealthcare.com/RAC/pages/approved_issues .aspx  Region D HDI  https://racinfo.healthdatainsights.com/Public1/NewIssues.aspx Copyright 2010 INTERSECT HEALTHCARE, INC. 32
  33. 33. Links  Social Security Act  http://www.socialsecurity.gov/OP_Home/ssact/ssact-toc.htm  ICD-9-CM Official Guidelines for Coding and Reporting  http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm  CMS Internet Only Manuals (IOM)  http://www.cms.gov/Manuals/IOM/list.asp  National Coverage Determinations (NCDs)  http://www.cms.gov/MCD/overview.asp  Code of Federal Regulations (CFR) 42 CFR 400 (Appeal Process)  http://www.gpoaccess.gov/cfr/index.html 33 Copyright 2010 INTERSECT HEALTHCARE, INC.
  34. 34. Links  ICD-9-CM  http://www.cdc.gov/nchs/icd/icd9cm.htm  Coding Clinics (AHA)  http://www.ahacentraloffice.org/ahacentraloffice/shtml/Products.shtml  CPT, CPT Assistant (AMA)  https://catalog.ama-assn.org/Catalog/cpt/cpt_home.jsp  RAC Statement of Work  http://www.cms.hhs.gov/RAC/downloads/Final%20RAC%20SOW.pdf  Limitation on Liability; Social Security Act § SEC. 1879. [42 U.S.C. 1395pp]  http://www.ssa.gov/OP_Home/ssact/title18/1879.htm 34 Copyright 2010 INTERSECT HEALTHCARE, INC.
  35. 35. Links  Determining Limitation on Liability (42 C.F.R. § 411.406)  http://www.gpoaccess.gov/cfr/index.html  Determining “acceptable standards of practice by the local medical community” (HCFA Ruling 95-1)  http://www.cms.hhs.gov/Rulings/CMSR/list.asp  American College of Cardiology  http://www.cardiosource.org  American Thoracic Society  http://www.thoracic.org/statements/index.php  RAC Demonstration Project  http://www.cms.gov/RAC/02_ExpansionStrategy.asp 35 Copyright 2010 INTERSECT HEALTHCARE, INC.
  36. 36. Research Tips  Start with the Decision Letter  Follow all Leads  Match the Regulation or Guideline Year to the DOS  Develop a Library of Resources  PDF Documents  Bookmark Web Pages  Create Reusable Appeal Letter Templates  Include Acceptable Standards of Medical Care in the Community the Regulation Year to the DOS Copyright 2010 INTERSECT HEALTHCARE, INC. 36
  37. 37. Thanks for attending! Research! Research! Research! Download, Bookmark, Print, Save, Store, File, Organize, Share, Use - Appeal! You can reach me at: dwilson@intersecthealthcare.com 410-252-4343 ext 16 37 Copyright 2010 INTERSECT HEALTHCARE, INC. Blog: http://www.intersecthealthcare.com/index.php/category/blog/compliance-corner/

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