New Rules to Streamline Medicare Claim–Denial Appeals Process
nnCheck out this article about a half-dozen changes to the adjudication of Medicare claims-denial appeals that are designed to ease a backlog of cases.nnThe new rules for Medicare claim-denial appeals feature several changes crafted to ease administrative burdens and speed reductions in a backlog nearing 1 million cases. The new rules went into effect March 20. “This final rule streamlines administrative appeal processes, increases consistency in decision making across appeal levels, and improves efficiency for both appellants and adjudicators,” a Department of Health and Human Services fact sheet on the new rules says.nnThursday afternoon, three officials at the Office of Medicare Hearings and Appeals (OMHA) led a presentation to walk healthcare providers through more than a dozen significant changes in the new rules. OMHA reports directly to Health & Human Services Secretary Tom Price, MD.nnDisputed Medicare claims of more than $160 can be appealed to Administrative Law Judges (ALJs) and attorney adjudicators for reviews that can include a hearing. The last stop before federal court is the Medicare Appeals Council.nnThursday’s Medicare Learning Network (MLN) presentation featured a half-dozen changes to the claims-denials appeals process at the ALJ-level that are designed to either quicken or streamline adjudication:n
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- Attorney adjudicators are a new position at the ALJ level created this year to help clear the appeal backlog. “Attorney adjudicators are not authorized to conduct a hearing, which also means they cannot issue a decision in any case where a hearing is necessary,” said Jason Green, JD, chief adviser at OMHA. “However, attorney adjudicators can issue decisions when a hearing is not required, including cases where the records support a fully favorable decision.”
- OMHA-100 form: This new form “is user-friendly and helps walk you through all the information required for a valid request for ALJ hearings,” OMHA’s Amanda Axeen, JD, said during the presentation. OMHA-100 can be used to request new hearings or review of appeal dismissals. The new form is not mandatory as long as previously required documents and information are filed.
- Statistical Sampling Initiative: This new option for appeal adjudication “draws a random sample from a universe of claims and extrapolates—or projects—from the sample to the entire universe of claims,” OMHA’s Anne Lloyd said during the presentation. For example, she said a statistician could pick a sample of 30 claims out of a total of 1,000 for review in a ALJ hearing.
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nThis article was originally posted on HealthLeadersMedia.com
Medicare Advantage: You have probably heard some industry buzz about the recent investigations (and settlements) into risk adjustment fraud with several of the major insurers. United Health Group along with others, are accused of manipulating diagnosis codes to make patients appear to be sicker to achieve higher reimbursement outcomes via the Medicare Advantage program. Medicare Advantage allows providers to participate in a reimbursement model based on risk adjustment factor. Risk adjustment factor is determined by diagnosis complexity and specificity. Providers who treat patients that are sicker or have more chronic conditions are reimbursed at a higher rate per patient, regardless of actual health outcomes. This all relates back to the importance of understanding the False Claims Act and maintaining an ongoing internal compliance program. If you are still in the mindset of thinking accuracy with regards to reporting diagnosis codes is meaningless – Think Again!n
nnSmall practices could add points to their total performance scores in the merit-based incentive payment system and may qualify for an exemption from EHR requirements.nnMore small practices may qualify for exclusions from the Quality Payment Program (QPP), claim hardship exceptions from electronic health record (EHR) requirements, and earn automatic bonus points if the proposed QPP rule released June 20 is finalized.nnThe Centers for Medicare & Medicaid Services has proposed increasing two low-volume thresholds that would grant additional exclusions in 2018:n
nnEmotional Intelligence (EI) – Many of us are familiar with IQ tests, which measure our intellectual abilities and intelligence. Many of us also believe that having a high IQ makes you the best candidate for any job. However, employers are focusing more on emotional intelligence rather than academic aptitude. Emotional intelligence is the capability of individuals to recognize their own and other people’s emotions, discern between different feelings and label them appropriately, using emotional information to guide thinking and behavior, and manage and/or adjust emotions to adapt to environments or achieve one’s goal(s). EI can be a huge asset to employers because it is the one part of the human psyche that we can develop and improve by learning and practicing new skills. We’ve all met very clever and intelligent people who nonetheless had no idea about how to deal with people, and the reverse. How we manage ourselves and the relationships we have with others can have a lasting impact on future opportunities.
Check out this article regarding the announcement that Anthem has calmed controversy over Colorado’s health insurance by submitting its proposed plan for 2018 to the state. nnHealth insurance giant Anthem announced late Monday that it has submitted proposed 2018 plans to the state, easing fears that it might back out of Colorado’s health insurance exchange and leave residents of several counties without an insurance choice.nnBut an Anthem spokesman declined to provide specifics on those plans — including where the company expects to offer them — meaning it remains unclear if Anthem will continue to provide coverage to the same number of Coloradans it currently does.nnMonday was the deadline for insurers hoping to participate next year on the Connect for Health Colorado exchange to file their proposed plans and rates with the state Division of Insurance for review. The exchange is a one-stop shop for health insurance on the individual market — where people buy their own plans, instead of receiving coverage through an employer or the government.n
nnCPT code 20680 requires the provider to incise through muscle layers and into the bone, necessitating a more complex, layered closure. The physician makes an incision overlying the site of the implant using deep dissection to visualize the implant (usually below the muscle level and within bone), using instruments to remove the implant from the bone. The physician repairs the incision in multiple layers using sutures, staples, etc. CPT Assistant and the AAOS (American Academy of Orthopedic Surgeons) direct that the 20680 code is to be billed once per fracture site, rather than based on the number of pieces of hardware removed or the number of incisions made to remove the hardware from one fracture site or original area of injury. Billing 20680 more than once is only appropriate when hardware removal is performed in a different anatomical site unrelated to the first fracture site or area of injury. It is fraudulent to send a patient to the OR/ASC for the sole purpose of seeking reimbursement for 20680, when medical necessity is not supported.