presents the power behind standards of care in

Presents

The Power Behind Standards of Care in Successfully Appealing Medical

Necessity DenialsTo join the audio conference

Call-in toll number (US/Canada):1-562-247-8321

Access code: 618-623-001

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GoToWebinar Attendee Participation

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Housekeeping

• Free CEUs are offered to AHDAM members only.• To obtain CEUs, you must attend the live webinar for at least 50 minutes and

complete the survey that will pop up automatically for you at the end of thewebinar.

• CEU certificates will be emailed to you.• CEUs are not available for watching the recording of this live webinar.• Disclosure: No individuals in a position to control content for this

activity have any relevant financial relationships to declare.

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CEUs/Contact Hours

• From the survey you will be prompted to select desired CEUs:• Association of Clinical Documentation Improvement Specialists (ACDIS):

Certified Clinical Documentation Specialist (CCDS)• National Association of Healthcare Revenue Integrity (NAHRI): Certification in

Healthcare Revenue Integrity (CHRI)• Commission for Case Manager Certification (CCMC): CCM board certified case managers• American Health Information Management Association (AHIMA): Certified health

information management professionals• American Nurse Credentialing Center (ANCC): Continuing nursing education

• This nursing continuing professional development activity was approved by the Northeast Multistate Division Education Unit, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

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Next Webinar

Find Appeal Success byCreating Your Own Evidenced-Based Guidelines Library

Wednesday, November 3, 20212 P.M. Eastern TimeFeatured Speakers:

Denise Wilson, Senior Vice President Intersect Healthcare and Denial Research Group/AppealMasters

President, AHDAMRegister at www.ahdam.org

http://www.ahdam.org/

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AHDAM – Association for Healthcare Denial and Appeal Management

• The nation’s only association dedicated to Healthcare Denial and Appeal Management.

• Our mission is to support and promote professionals working in the field of healthcare insurance denial and appeal management through education and collaboration.

• Our vision is to create an even playing field where patients and healthcare providers are successful in persuading medical insurers to make proper payment decisions.

www.ahdam.org

http://www.ahdam.org/

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Host & Presenter

Denise Wilson MS, RN, RRT, Senior Vice President, Denial ResearchGroup/AppealMasters, President, AHDAM

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing.

Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level. Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning healthcare denials.

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Presenters

Kendall Smith, MD, Chief Physician Advisor, Denial ResearchGroup/AppealMasters, Advisory Board Member, AHDAM

Dr. Kendall Smith is a Senior Fellow in Hospital Medicine (SFHM) and currently actsas Chief Physician Advisor for AppealMasters, a leading appeal educator and appealservices firm for hospitals and health systems. He’s been deeply involved in denialand appeals management throughout his hospitalist career, working collaborativelywith UR/Case Management departments as well as Managed Care and Hospital C-Suite executives.

His familiarity with managed care denials led him to design and implement a number of CDI programs, including those at the Cleveland Clinic in Florida and the MedStar Washington Hospital Center. He has served as a physician leader on hospital revenue cycle management teams while also serving as the Physician Advisor for Clinical Resource Management. Dr. Smith is also an AHIMA ICD-CM/PCS approved trainer/ambassador.

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Disclaimer

The Association for Healthcare Denial and Appeal Management (AHDAM) publishes and distributes materials on its website that are created by our members or invited industry subject matter experts for the benefit of all AHDAM members. AHDAM does not certify the accuracy or authority of these materials.

These materials are distributed and presented as research information to be used by AHDAM members, in conjunction with other research deemed necessary, in the exercise of AHDAM members’ independent professional judgment. AHDAM claims no liability in relation to reliance on the content of these materials. The views expressed in the materials are the views of the material’s authors and do not necessarily represent the views of AHDAM. Any references are provided for informational purposes only and do not constitute endorsement of any sources.

There are no conflicts of interest to declare for any individual in a position to control the content of this presentation.

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Learner Outcomes

At the end of the presentation, the learner will be able to:• Make use of standards of care in the medical community to support

an appeal argument that services provided for the patient were medically necessary and appropriate.

• Define a standard of care in the medical community.• Describe two strategies for researching standards of care.• Appropriately incorporate standards of care in medical necessity

appeal arguments to support the medical necessity and appropriateness of the services performed.

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Standards of Care – As Defined by Medical Experts in the Field

AKA

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Clinical Practice GuidelinesNational Center for Complementary and Integrative Health (NIH)• “Clinical practice guidelines are systematically developed statements to assist

practitioner and patient decisions about appropriate health care for specific clinical circumstances.”(Institute of Medicine, 1990)

• Issued by third-party organizations…define the role of specific diagnostic and treatment modalities in the diagnosis and management of patients…based on evidence from a rigorous systematic review and synthesis of the published medical literature.

• These guidelines are not fixed protocols...but are intended for health care professionals and providers to consider…not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider.

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Clinical Practice Guidelines

Clinical Practice Guidelines We Can Trust.Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.

Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines; Graham R, Mancher M, Miller Wolman D, et al., editors. Clinical Practice Guidelines We Can Trust. Washington (DC): National Academies Press (US); 2011. Summary. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209538/

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To be trustworthy, guidelines should• be based on a systematic review of the existing evidence;• be developed by a knowledgeable, multidisciplinary panel of experts and

representatives from key affected groups;• consider important patient subgroups and patient preferences, as appropriate;• be based on an explicit and transparent process that minimizes distortions, biases,

and conflicts of interest;(continued on next slide)

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(continued)• provide a clear explanation of the logical relationships between alternative care

options and health outcomes, and provide ratings of both the quality of evidence and the strength of the recommendations; and

• be reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations.

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The Significance of Standards of CareAcceptable Standards of Medical Care in the Community

V. ACCEPTABLE STANDARDS OF PRACTICE—APPLICATION

“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.”Department of Health and Human Services, Health Care Financing Administration (1995, December). HCFA Ruling 95-1. Retrieved from http://www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/Downloads/HCFAR951.pdf.

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The Significance of Standards of Care

AETNA: Aetna states their Clinical Policy Bulletins are based on:• Peer-reviewed, published medical journals• A review of available studies on a particular topic• Evidence-based consensus statements• Expert opinions of health care professionals• Guidelines from nationally recognized health care organizations

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ANTHEM BCBS: • Medical policies generally apply to all of Anthem’s plans• Local variations may exist• Anthem has developed clinical UM guidelines • Anthem is also licensed to use MCG™ guidelines• Anthem also has the right to customize MCG™ guidelines based on determinations

by its Medical Policy & Technology Assessment Committee

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UNITED HEALTHCARE: • Uses generally accepted standards of medical practice• Credible scientific evidence published in peer-reviewed medical literature • Generally recognized by the relevant medical community• Standards based on physician specialty society• Recommendations or professional standards of care• Other evidence-based, industry-recognized resources and guidelines, such as the

Milliman Care Guidelines®

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If you accept a commercially published Care Guideline as the final word in medical necessity, what chance do you have to appeal a denial?

All payer guidelines are based on acceptable standards of medical care in the community.

• IQ/MCG are screening tools• Not endorsed by Medicare

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NCQA Criteria:

The organization uses written criteria based on sound clinical evidence to make utilization decisions, and specifies procedures for appropriately applying the criteria.

The organization applies objective and evidence-based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services.

The organization:1. Has written UM decision-making criteria that are objective and based on medical evidence.2. Has written policies for applying the criteria based on individual needs.3. Has written policies for applying the criteria based on an assessment of the local delivery system.4. Involves appropriate practitioners in developing, adopting and reviewing criteria.5. Annually reviews the UM criteria and the procedures for applying them, and updates the criteria when appropriate.

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Researching Standards of Care

Credible Sources• Professional Guidelines• Published Research Studies• Peer-reviewed journals / Periodical publications• PubMed (National Library of Medicine/National Institute of Health)• Sources of professional reference [Medscape Reference]• Manufacturers’ information• Government and agency alerts [MedWatch, CDC]• Electronic healthcare updates [AHRQ; Medscape]• Textbooks

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Researching Standards of CareThe “Gold Standard” = relevant professional societies such as the American College of Cardiology or American Academy of Orthopaedic Surgeons

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• Does the article address the patient’s nuances?• Does the article support medical necessity or prove the need for

admission/treatment?• Was the article published before the denial date?• Does the article cite the most current or established standards? – old doesn’t mean

outdated• Is the article from a country that practices medicine like the U.S.?

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• Start an electronic library to save favorite articles, quotes, and arguments • Make it accessible to everyone• Update it consistently • Make it easy to copy & paste

• Cite the references professionally (APA preferred)• BibMe: http://www.bibme.org/• Purdue OWL: https://owl.english.purdue.edu/owl/section/2/10/

• Create snippets that include only relevant information – less is more

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Asthma - Standards of Care

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Atrial Fibrillation - Standards of CareSource/Reference January, C., Wann, L., Alpert, J., Calkins, H., Cleveland, J.,

Cigarroa, J., ... Yancy, C. (2014). 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 130, 199-267. As found on: http://circ.ahajournals.org/content/130/23/e199.full.pdf

Evidence Based Guideline/Practice Guideline Recommendation

• “Frequent hospitalizations, hemodynamic abnormalities, and thromboembolic events related to AF result in significant morbidity and mortality.” [p. 205]

• “AF is associated with a 5-fold increased risk of stroke, and stroke risk increases with age. AF-related stroke is likely to be more severe than non–AF-related stroke.” [p. 205]

• “AF is also associated with a 3-fold risk of heart failure (HF) and a 2-fold increased risk of mortality. [p. 205]

• “…initially asymptomatic patients may develop tachycardia-induced ventricular dysfunction and HF (tachycardia-induced cardiomyopathy) when the ventricular rate is not adequately controlled.” [p. 205]

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Standards of Care – Case Study - Diabetes

On May 25, 2020, Jane Doe, age 63 with known diabetes controlled with oral medication, presented to the hospital emergency department (ED) with a high blood sugar reading from a home glucometer. Ms. Doe was suffering from polyuria, polyphagia, and polydipsia. In the ED, her glucose level was critically elevated at 894 with a significantly elevated anion gap > 30 indicating metabolic acidosis, abnormally high BUN 40, and an abnormal creatinine 2.00 indicating renal insufficiency. Ms. Doe did not take insulin at home (pp. 23 & 32).Ms. Doe was emergently treated in the ED with intravenous (IV) fluids with potassium, IV insulin drip, IV magnesium, IV phosphate, and oral potassium (pp. 21-22).Ms. Doe was admitted to the medical intensive care unit (MICU) with diabetic ketoacidosis (DKA) and acute kidney injury (pp. 31 & 59).

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Standards of Care – Case Study - DiabetesSource/Reference American Diabetes Association, Diabetes Care 2004 Jan; 27(suppl 1): s103-s103. As

found on: https://doi.org/10.2337/diacare.27.2007.S103Evidence Based Guideline/Practice Guideline Recommendation

Indications for inpatient admission [p. S103]• Life-threatening acute metabolic complications of diabetes.• Substantial and chronic poor metabolic control that necessitates close monitoring

of the patient to determine the etiology of the control problem, with subsequent modification of therapy.

• Severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes.

• Uncontrolled or newly discovered insulin-requiring diabetes during pregnancy.• Institution of insulin-pump therapy or other intensive insulin regimens.• Diabetic ketoacidosis • Hyperglycemic hyperosmolar state • Hypoglycemia with neuroglycopenia• Progression of chronic cardiovascular, neurological, renal, and other diabetic

complications

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Outpatient Denials and Appeals

• If there an applicable Clinical Policy Bulletin (CPB) published by the payer:• Is the diagnosis code on the claim supported by the CPB?• Is additional documentation needed to support medical necessity, such as physician

office notes?• Was the additional documentation sent in response to the request for records or first

level of appeal/reconsideration? • Verify documents sent; keep copies

• If the supporting documentation does not meet all required elements of the CPB, is there a reasonable explanation why?

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CMS – Medicare Coverage Databasehttps://www.cms.gov/medicare-coverage-database/search.aspx

• National Coverage Determinations (NCDs) – apply to all Medicare beneficiaries• Local Coverage Determinations (LCDs) – apply to Medicare beneficiaries within the

Medicare Administrative Contractor (MAC) jurisdiction

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Best Practices to Prevent Denials• Develop payer-specific checklists for pre-procedure documentation review

• Start with top 5 payers• Engage department heads to support pre- and post-procedure documentation audits• Educate providers and their staff on documentation requirements

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Standards of Care Take-Aways

• Standards of care are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.

• All payer guidelines are based on acceptable standards of medical care in the community.

• Use credible sources to research standards of care• Peer-reviewed journals • Relevant Professional Societies

• Create snippets from the standards of care for support of medical care provided • Harness the power of standards of care in appeal arguments

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Q&A

Thank you for joining us for today’s event!

If you have suggestions or ideas on how we can serve you better, we want to hear them. We are here for you!

AHDAM: [email protected]

Presenters:[email protected]@intersecthealthcare.com

mailto:[email protected]

presents the power behind standards of care in

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