The Art of Appeals

1. The Art of Appeals Presented by Lori Dafoe, CPC

2. Agenda • Review what to look for in an appeal, while reviewing an actual example. • Review different appeal process for various insurance carriers. • Review additional examples. • Questions

3. Understand: • Understand the denial. • Understand what your provider is billing and why. • Understand basic coding principles. • Understand the carrier’s requirements. • Understand your rights.

4. APPEAL • Ask • Probe • Provide Evidence • Explore • Affirm • Link

5. Ask • Why is the claim being denied? • NEVER assume.

6. ASK

7. ASK

8. ASK • Actual reason for non-payment: Prior authorization required.

9. Probe • Research to make sure it was billed correctly.

10. Probe • Review documentation for appropriate coding. • Check for authorization. • Review medical policy

11. Provide Evidence • Use Medical Policy to refute denial. • Provide evidence to support your stance (clinical studies, CPT Assistant Articles, etc.)

12. Provide Evidence • Knowledge of procedure. • Policy allows payment for drug eluting stents under certain conditions.

13. Explore • Know the specific carrier’s appeal process.

14. Explore • Complaint can be made verbally or in writing. If submitting in writing, specific cover sheet/form must be completed. • Level 1 Appeal may be submitted verbally or in writing. • Complaint and Level 1 must be submitted within 365 calendar days from the initial process date.

15. Appeal Letter • Patient X underwent an angiography with left heart catheterization and subsequent stenting of the right coronary and left circumflex (obtuse marginal branch). Your company has denied payment for the stenting based on a policy that indicates prior authorization is required. The purpose of this letter is to request a review of the claim based on medical necessity, and to ask that this policy for prior authorization be assessed and revised.

16. Appeal Letter • First, please note that although prior authorization was not obtained, this service was medically necessary. The patient has a prior history of quadruple coronary bypass grafting and stenting to the right coronary artery. He presented to follow up from a hospitalization where he had experienced new onset symptoms of unstable angina. Due to his history, symptoms, and the fact that he lives 133 miles away from adequate treatment (Forks, WA), it was determined that stress testing would not be prudent, and the heart catheterization was scheduled.

17. Appeal Letter • Secondly, the policy indicates that drug-eluting stents are considered medically necessary when stents the length of 15mm or longer are placed in a single vessel, or for treatment of left main coronary disease. The patient met both of these criteria. The operative and prior office notes are included for your review.

18. Appeal Letter • Finally, we would like to request a Medical Review of the policy in question (also attached for your review). Prior authorization for this service is not feasible. The provider does not know if stenting will be required until after the angiography/heart catheterization is performed, nor can he tell where a possible blockage may be or what percentage the vessel is occluded. To either stop the procedure to obtain prior authorization when needed, or stop the procedure, obtain prior authorization, and reschedule the stenting would put the patient at greater risk for complications.

19. Appeal Letter • For these reasons, we ask that you reconsider payment for our claim, and revise the policy to allow adequate care for our patients, your beneficiaries. After careful consideration of the medical record and supporting documentation we anticipate the reversal of your initial decision and issuance of payment in full for our claim. If you have any questions or require further information, please contact me. Should you choose to deny this request, I ask that you send written documentation including the criteria and/or guidelines used to make your determination.

20. Affirm • Follow up! • Take next step as needed.

21. Affirm • Level 2 Appeal MUST be submitted in writing and received within 15 calendar days from the receipt of the Level 1 appeal denial • Level 3 Mediation. Non-binding mediation may be requested if there is a disagreement with the second level of appeal. Mediation request must be submitted in writing and received within 30 calendar days from the Level 2 appeal notification. Mediator fees are shared equally between both parties.

22. Link • Document in the patient’s account what you have done to resolve the claim.

23. Link • 01/14/14 Spoke to insurance rep. She could not explain reason for denial. Will send back for reprocessing. Biller A • 01/18/14 Rec’d voice mail from insurance. States denial was for no authorization. To coder for review. Biller A • 01/25/14 Biller reviewed, coding accurate, planned procedure, no auth obtained. To compliance for review. Coder A

24. Link • 01/25/14 Compliance reviewed, coding correct, auth not obtained but service was medically necessary. Disagree with prior auth policy. Letter of appeal drafted and given to Biller A to submit. Compliance Analyst A. • 02/27/14 Appeal 1 denied. To Compliance for review. Biller A. • 02/28/14 Advised Biller A to submit Level 2. Compliance Analyst A.

25. Link • 03/21/14 Level 2 appeal denied. To Compliance for review. Biller A. • 03/21/14 Spoke with provider representative regarding Mediation. Would like peer-to-peer review between our cardiologist and insurance medical director. Rep will call back to schedule. Compliance Analyst A. • 03/27/14 Rep called back, peer review scheduled for 04/09/14 @8am. Compliance Analyst A.

26. Link • 04/09/14 Peer-to-peer review completed. Medical Director agreed. Will overturn denial and allow payment. Will also take this to higher level to make sure prior authorization policy for cardiac services is reviewed and modified. Reference number for call #1234 given to help with any other denials we may receive until policy is updated. Compliance Analyst A.

27. APPEAL • Ask • Probe • Provide Evidence • Explore • Affirm • Link

28. Appeal Process by Carrier • Aetna • Cigna • KPS • Medicare • Premera • Regence • United Healthcare

29. Aetna, cont. • Timeframes for reconsiderations and appeals:

30. Aetna Health care providers can use the Aetna dispute and appeal process if they do not agree with a claim or utilization review decision. The process includes: • Reconsiderations: Formal reviews of claims reimbursements or coding decisions, or claims that require reprocessing. • Level 1 appeals: Requests to change a reconsideration decision, an initial utilization review decision, or an initial claim decision based on medical necessity or experimental/investigational coverage criteria. • Level 2 appeals: Requests to change a Level 1 appeal decision.

31. Aetna, cont. To help us resolve the dispute, we'll need: • The reasons why you disagree with our decision • A copy of the denial letter or Explanation of Benefits letter • The original claim • Documents that support your position (for example, medical records and office notes)

32. Aetna, cont. • Must have member complete a form if filing an appeal on behalf of the member. • http://www.aetna.com/faqs-health-insurance/documents/Authorized-Representative-Request-Form.pdf

33. Aetna, cont. • Mailing address for reconsiderations for WA: Aetna Provider Resolution Team PO Box 14079 Lexington, KY 40512-4079 http://www.aetna.com/health-care-professionals/disputes-appeals/disputes-appeals-overview.html

34. Cigna • Time frame: 180 days

35. Cigna • Requests for Claim Processing Error/Missing Information vs. Payment Appeal Process

37. http://www.cigna.com/assets/docs/health-care-professionals/MM_002_appeal_request_for_provider_payment_review.pdfhttp://www.cigna.com/assets/docs/health-care-professionals/MM_002_appeal_request_for_provider_payment_review.pdf

41. Cigna/MedSolutions • Access to Imaging Guidelines requires login. • https://www.medsolutionsonline.com/portal/server.pt/community/medsolutions_online/223

42. Chest CT Denied (71260) • PSR called Cigna, was told no authorization needed. Given reference number for call. • Claim denied for no authorization. • Two-fold appeal: 1.) Cigna Rep said no auth required. 2.) Service was medically necessary.

43. Chest CT Denied (71260), cont. • Med Solutions denied as service would not have been authorized based on their clinical guidelines. • Cigna denied because service was not authorized.

44. Chest CT Denied (71260), cont. • We are in receipt of a letter denying our appeal for a CT of the thorax with contrast.  The letter admits that there were extenuating circumstances that prevented pre-certification in a timely manner, but continues to deny based on medical necessity.  This letter indicates that this is the final internal level of appeal.  We disagree with the manner in which this claim has been handled and are requesting special dispensations regarding this unique claim situation.

45. Chest CT Denied (71260), cont. • Please note that our scheduler contacted Cigna’s provider customer service team to request prior-authorization information.  The representative mis-quoted the patient’s benefits.  We were told that no prior authorization was required as the customer service representative sees this group in your Medical module as PHS, which does not require an authorization.  However, upon further investigation it has been determined that this group is actually PHS plus, which does require an authorization.  We were told to request an authorization from Med-Solutions, which we did.  This was denied as Med-Solutions does not allow retro-authorizations.  We then appealed the service with Cigna, and the denial indicates the service was considered not medically necessary.  It further states that claim payment policies do not allow for consideration of medical necessity once the procedure has been completed except for cases considered urgent with supporting documentation presented for review by the Medical Director. 

46. Chest CT Denied (71260), cont. • First of all, I understand that Cigna requires prior authorization from MedSolutions, and we have done our best to educate all staff members of this.  However, in this instance the employee was covering in the department and was not aware of this protocol specific to Cigna.  As such, she called the telephone number on the back of the patient’s insurance card and was subsequently given erroneous information.

47. Chest CT Denied (71260), cont. • Secondly, please note the patient, who had already been evaluated in the Emergency Department, presented with complaints of shortness of breath, and chest pain.  Due to the patient’s symptoms and family history of pectusexcavatum, Dr. Dawson ordered a CT of the thorax with contrast.  Attached, please find a medical journal supporting the testing for this condition.  I have also attached a copy of the patient’s office visit and subsequent CT results.  I have also included a copy of the front and back of the insurance card, which you can see does not specify MedSolutions must be contacted for prior authorization of services.

48. Chest CT Denied (71260), cont. • I understand that MedSolutions does not consider this test to be medically necessary, but our physician did.  Additionally, I have provided a clinical case study in which CT is considered the best diagnostic tool for symptomatic patients at rick of PE to estimate the deformity and whether there are associated anomalies. • In this instance, to not allow a peer-to-peer review because the service was already performed is unfair.  The service was performed in good faith, based on the information given by the staff at Cigna.  • For these reasons, we are asking that the Medical Director review this and after careful review of the medical record and supporting documentation, we anticipate the reversal of your initial decision and issuance of payment in full for our claim.  Should you choose to deny our request, I would like for you to send documentation outlining our right to an independent review organization (IRO). If you have any questions, or need additional information, please do not hesitate to contact me.

49. Cigna, cont. • Additional Appeal Options: Arbitration

50. KPS • Information can be found on the paper remits, or on the KPS website in the provider portal, under the 2014 KPS Practitioner Manual • Timeframe: 30 days • Good Faith Discussions