Medicare Advantage Plans and Clinical Validation

cseluke

What are people seeing with Medicare Advantage plan post-payment denials? We have seen a big increase in MA clinical validation and coding DRG validation denials. Can you share your strategies for dealing with this onslaught? Do you get authorization from your patients to act as their agents in appeal? Do you have access to the terms of your contracts with MA plans? Does anyone have knowledge of ERISA regs and how they apply to appeal rights for group MA plans? 

jcarriveau1

We have seen a big increase in clinical denials from UHC and Humana, despite excellent documentation and support by physicians and good coding of same.  We are now using a physician to argue the cases with their physician, rather than using  a coder to do it.  We are also turning some cases over to CMS to follow up on these two groups, as their denials are often flagrant. (they use the excuse that it doesn't meet their own internal definitions, without regard to national medical standards of care).  We are having our contracts changed as each one comes up for renewal to include the important aspect of physician's clinical impressions which meet standards of care and our attorneys,  HIM, coding and CDI are a part of the conversations with payor contracting folks.

cseluke

Thanks for your response. What is your process for turning cases over to CMS? You can pm me if you wish. My email is cathy.seluke@mainegeneral.org. 

jwright@chmed.org

We too are seeing an increase in the Clinical validation denials. We use an external company (Executive Health resource now "Optum") to take over the appeal. Their physicians do a nice job crafting a letter for appeal but we still are not seeing many of these overturned. I do have a few cases that we have exhausted all our appeal levels with the insurance so we are taking them to an external appeal level. Excellus BC/BS is one of them and also UHC can be difficult for us. Having language in our contract is a good idea. I will look into this more.

cseluke

We use EHR for some clinical validation appeals as well. I write most of them myself but outsource when I get overwhelmed or I want to see if EHR has some new arguments. We have not been able to overturn most of the denials, and EHR does not have a better track record than the ones I write myself. What are you seeing for diagnoses? We see sepsis, respiratory failure, encephalopathy, severe PC malnutrition, and pneumonia. They never seem to find any underpayments, however!

morris-jeff@CooperHealth.edu

cseluke said:

What are people seeing with Medicare Advantage plan post-payment denials? We have seen a big increase in MA clinical validation and coding DRG validation denials. Can you share your strategies for dealing with this onslaught? Do you get authorization from your patients to act as their agents in appeal? Do you have access to the terms of your contracts with MA plans? Does anyone have knowledge of ERISA regs and how they apply to appeal rights for group MA plans? 

Also seeing a spike in DRG downgrades/denials and others in our area are experiencing the same thing. What we've seen is that we get a letter stating that the DRG was denied and stating what they are changing it to. There doesn't seem to be an appeals process with these payers (unless someone in our organization is getting a denial letter and it's not making it to our Coding Managers). How does one refer these types of denials to CMS?

Thanks,

Jeff