appeals refunds recoupments webinar materials … · classes are presented in ... please be advised...

WELCOMEto a

PMI WEBINAR PRESENTATION

www.pmiMD.com

PMI presents: Sunjanel Avecilla

on the topic:Appeals, Refunds and Recoupment Requests

Welcome to Practice Management Institute’s Webinar and Audio

Conference Training. We hope that the information contained herein will

give you valuable tips that you can use to improve your skills and

performance on the job. Each year, more than 40,000 physicians and office

staff are trained by Practice Management Institute. For over 25 years,

physicians have relied on PMI to provide up-to-date coding,

reimbursement, compliance and office management training. Instructor-led

classes are presented in 400 of the nation’s leading hospitals, healthcare

systems, colleges and medical societies.

PMI provides a number of other training resources for your practice,

including national and regional conferences for medical office

professionals, self-paced certification preparatory courses, online training,

educational audio downloads, and practice reference materials. For more

information, visit PMI’s web site at www.pmiMD.com

Please be advised that all information in this program is provided for

informational purposes only. While PMI makes all reasonable efforts to

verify the credentials of instructors and the information provided, it is not

intended to serve as professional or legal advice. The information provided

is general in nature. Depending on the particular facts at issue, it may or

may not apply to your situation. Participants requiring specific guidance

should contact their legal counsel. CPT® is a registered trademark of the American Medical Association.

Practice Management Institute®

9501 Console, Suite 100 | San Antonio, Texas 78229-2033

tel: 1-800-259-5562 | fax: (210) 691-8972

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Appeals, Refunds & Recoupment RequestsPresented by:

Sunjanel Avecilla, CMC, CPC, CMIS, CMOM

Faculty, Practice Management Institute

Denials

� According to the AMA

- 2010 - seven largest insurers incorrectly pay one in five claims!

- 2011 - commercial health insurers have an average claims-processing error rate of 19.3 percent

(� 2% compared last year)

Practice Management Institute www.pmiMD.com

Webinar/Audio ConferenceApril 24, 2012

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2011 National Health Insurer Report Card (NHIRC)What are the most frequently reported reason codes for a denial?

�96: Non-covered charge(s).�26: Expenses incurred prior to coverage�197: Precertification/authorization/notification absent.�55: Procedure/treatment is deemed experimental/investigational by the payer.�204: This service/equipment/drug is not covered under the patient’s current benefit plan�16: Claim/service lacks information which is needed for adjudication.�49: These are non-covered services because this is a routine exam or screening procedure

done in conjunction with a routine exam.

Aetna Anthem Cigna Humana UHC

Code % Code % Code % Code % Code %

96 36.74 26 25.51 96 29.20 96 42.47 16 43.89

197 10.97 204 21.63 51 27.86 16 19.84 96 21.70

55 9.45 16 17.08 49 7.06 125 10.07 49 4.96

2011 National Health Insurer Report Card (NHIRC)



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Appeals

AppealsAMA:

� a surgical practice in Chicago that recovered $19,000 over 6 months from appealing a single type of underpaid claim.

� practice in New Jersey became the “recouper”instead of the recoupee



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What does all this mean?WE NEED TO LOOK AT OUR CLAIMS

CLOSER AND APPEAL!

Health Insurance Companies� are FOR-profit businesses � MAKING MONEY!

� dictate what IS covered and cost of service

� have increased restrictions & constantly finding new reasons to deny and/or underpay claims � providers lose revenue & don’t realize it



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The Medical Practice� inappropriate claim denials � and payments ��

� claims editing software in processing systems

� practices believe appealing claims will create an increased administrative burden

Combat these erroneous payment reductions & denials.

Be diligent in submitting appeals!

FixWriting an Effective and Powerful Appeal letter!

� simplest & best action

� taken for granted & overlooked

� not appealing = �� revenue



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Tips For Writing An Effective and Powerful Appeal Letter1. Read and understand your EOB

– what gets studied gets improved

– not understanding the way plan reimbursement works could leave a lot of money on the table

Tips For Writing An Effective and Powerful Appeal Letter2. Carefully word your appeal

– address the issue, explain what you want

– simply resubmitting it again is not going to get their attention

– provide specific details the payer is looking for

– how you present your appeal can make a difference



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Tips For Writing An Effective and Powerful Appeal Letter3. Gather Supporting Documents

– support it with all necessary documents

– research thoroughly and include all :� medical notes, � operative reports, � research articles

– don’t overwhelm them with a lot of paperwork

– keep documentation concise and limited to what is being asked for



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Tips For Writing An Effective and Powerful Appeal Letter4. Time is the Essence

– stay within your deadline!

– consider faxing� may expedite review process� keep copy of the fax confirmation

– mailing:� send via Certified Mai� request Return Receipt to prove timely delivery

Tips For Writing An Effective and Powerful Appeal Letter5. Don’t Give Up!

– do not always have credentialed professionals reviewing initial appeals

– initiate a Level 2 appeal � reviewed by someone not part of initial review

– involve patient & employer



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– Report unfair health insurer business practices

� state medical associations

� national medical specialty societies

� file a complaint through the AMA’s Health Insurer Complaint Form (HPCF)


In 2011, Robert Liles* published an article discussing Losing Your Medicare Appeal at Reconsideration

- most Medicare providers have chosen not to appeal claims denials issued the QIC at the reconsideration level of appeal.

- Nationwide, in the last eight quarters: percentage of Part B QIC cases not being appealed has risen to 86%.

- Part A QIC cases, non-appealed cases have grown from roughly half to 75%.

* Robert W. Liles, Managing Member of Liles Parker PLLC



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Other Considerations for Refunds & RecoupmentsThe AMA reports private health plan recoupment is an increasing source of complaints from physicians.

Can a plan come back two or three years after the fact to demand recoupment?

- 19 states have legislations

- deadline can be tossed if the recoupment is being made because of suspected fraud or duplicate payments for the same service

Other Considerations for Refunds & Recoupments� California: Reimbursement request for the

overpayment of a claim shall not be made, unless a written request for reimbursement is sent to provider within 365 days of the date of payment on the overpaid claims.

� Texas: The insurer has no later than the 180 day after provider receives payment to recover an “overpayment”must provide written notice and mention specific reasons for request of recovery of funds.

� New York: Prohibit HMOs and other insurers from demanding refunds from a physician more than two years after the claim was initially paid.



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Additional Resources:� 2011 National Health Insurer Report Card: http://www.ama-

assn.org/resources/doc/psa/2011-nhirc-results.pdf

� Lose Your Medicare Appeal At Reconsideration? Don’t Throw in the Towel Just Yet – Consider the Consequences and Your Options (Robert Liles, Managing Partner at Liles Parker -Attorneys & Counselors at Law) http://www.aljappeal.com/2011/06/lose-your-medicare-appeal-at-reconsideration-don’t-throw-in-the-towel-consider-the-consequences-and-your-options/

Total Access Subscribers:Check our our Audio Library!

- Carrier Specific Rules: Get proven tips and strategies to eliminate denials due to carrier-specific rules and guidelines. Most clinics waste time and money calling carriers for every denial. Learn effective means for managing multiple carrier-specific rules.

- Writing Effective Appeals: There are several reasons why an insurance claim can become delayed or denied. Whether the issue is inadequate payment, denial or rejection, it is imperative to appeal claims in a timely manner with as much supporting documentation as possible. It is just as important to properly write an appeal in order for your claim to be reconsidered and result in your favor.

- Friend or Foe-Tactics of 3rd Party Payers: We will review of some of the major carriers. What are their profit margins? We will take a look into several of the payer's ratings by various specialty associations. What tactics do they use to not pay your claims? This session is geared toward assisting the practice with tactics to play the insurance game and get paid.



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Questions?

Developed and presented by:

Sunjanel Avecilla, CMC, CPC, CMIS, CMOM

Practice Management Institute

www.pmiMD.com

[email protected]

800.259.5562



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SAMPLE GENERIC APPEAL LETTER [Date] Attn: Provider Appeals Department [Address] [City, State, Zip Code] Re: Insured/Plan Member: Health Insurer Identification Number: Group Number: Patient Name: Claim Number: Dear [Health Insurer/Claims Adjudicator]: I/We am/are appealing your decision and request reconsideration of the attached claim that you denied on [date]. I/We feel these charges should be allowed for the following reason(s): [insert reasons] Thank you for reviewing and reversing this claim denial. If you require any additional information, please contact [staff name] at [telephone number] between the hours of [insert time period that staff is available to answer calls, e.g., 8:00a.m. – 5:00p.m.] Sincerely, [Physician, MD] Or [Practice Manager] Enclosed: Medical Records

Diagnostic Test Results CC: [Name of: Patient, Employer, Insurance Commissioner, Medical Director, etc]

SAMPLE LETTER FOR CODING ERROR [Date] Attn: Provider Appeals Department [Address] [City, State, Zip Code]

CORRECTED CLAIM Re: Claim reprocessing request Insured/Plan Member: Health Insurer Identification Number: Group Number: Patient Name: Claim Number: Dear [Health Insurer]: An incorrect code for [a/an] [name of procedure/service] was inadvertently submitted in error for the date of service listed above on [date]. [Example incorrect ICD-9-CM diagnosis code] This [name of procedure] should have been submitted with the diagnosis code of [correct ICD-9-CM code(s)] rather than [previously submitted ICD-9-CM code(s)] [Example incorrect CPT-4 procedure code] The procedure performed, [name of procedure], should have been submitted as [correct CPT-4 code] rather than [previously submitted CPT-4 code] Please correct this coding error and reprocess the attached corrective claim for payment. Sincerely, [Physician, MD] Or [Practice Manager] Enclosed: Medical Records

Corrected Claim Form

SAMPLE LETTER FOR MEDICAL NECESSITY [Date] Attn: Provider Appeals Department [Address] [City, State, Zip Code] Re: Denial Due to Medical Necessity Insured/Plan Member: Health Insurer Identification Number: Group Number: Patient Name: Claim Number: Dear Claims Adjudicator: As stated in the attached EOB, it is our understanding that this treatment for the above mentioned patient was denied pursuant to medical necessity. Your decision states that the following procedure [CPT-4 Code(s)] was not medically necessary. Please accept our appeal for this adverse determination. [Subjective, Objective, and Supporting Information] I have enclosed all documentation to support the medical necessity of this service. Copies of all medical notes including any diagnostic test results are enclosed for your review. The clinical findings revealed that the procedure or test [CPT-4 code(s)] were indicative of the diagnosis [ICD-9-CM]. Please re-evaluate you decision and contact me at your earliest convenience. Should you require any further information, please contact me at [phone no.]. Sincerely, [Physician, MD] Or [Practice Manager] Enclosed: Medical Records

Corrected Claim Form CC: [Name of: Patient, Employer, Insurance Commissioner, Medical Director, etc]