Fighting Back to Save Your Claim - California Orthopaedic Association
Contents
1. Addresses for appeal O Fresh person with each us appeal level Often higher level review Se idian Healthcare Solutions NEW SERVICES AND CODES With delay in ICD 10 new ICD 9 codes may appear Changes occur with Cat III codes watch for them ICD 10 crosswalk codes posted now for LCDs We will highlight new codes and services on our website www Noridianmedicare com E Sign up for automatic updates by e mail Sign up and use Endeavor on our website Sign up for webinars from Noridian on website Call our provider contact center line for info 1 855 609 9960 one stop for all Noridian problems 855 609 9960 one stop phone number for all Medicare problems www Noridianmedicare com E our website which is easily searchable wawww Sign Up For Medicare News Receive most recent um Be the first to receive Noridian C MS news J F pem news and m See all Regulation policy 2011 updates gt Payment reimbursement advice Workshop educational l event notices co Noridian hours of Reeve Medieress Latest Updates availability related notifications Free delivered to your CCMS computer P Endeavor Sign Up Today Free Secure Internet Website Verify Eligibility Check Claim and Check Status Miew and Print Remittance Advice Full or single claim Reopening Redetermination Requests Submit view a2. ARE FOR REVIEWS DO 4 5 6 7 CHECK FOR CORRECT DATES amp NAMES PATIENT amp DATES OF SERVICE CORRECT PHYSICIAN SUBMIT TIMELY AND TO CORRECT ADDRESS REQUESTED ON LETTER KEEP RECORD OF INDIVIDUAL ASKING FOR YOUR RECORDS AND WHY WHICH SERVICES THEY ARE ASKING FOR CHECK FOR LEGIBILITY CAN RETYPE NOTES IF ALSO SEND ORIGINAL CALL IF ANY QUESTIONS NORIDIAN EDUCATORS CAN HELP STATE MEDICAL amp PROFESSIONAL SOCIETIES MAY HAVE ANSWERS ALSO THEY OFTEN CONTACT US IF YOU HAVE PROBLEMS YOU CANNOT RESOLVE CALL OR CONTACT THE IDENTIFIED PERSON AT NORIDIAN AND ASK FOR ASSISTANCE CALL PROVIDER CONTACT CENTER FOR HELP YOU SHOW YOU CARE ABOUT THE SITUATION THE CONTACT ALONE MAY TEACH YOU HOW TO SOLVE THE PROBLEM amp FIX THE CLAIMS CALL NORIDIAN CALIFORNIA ORTHOPEDIC ASSOCIATION OR CMA FOR HELP MEDICARE CONTRACTORS CARE ABOUT GOOD RELATIONS WITH ORGANIZED ASSOCIATIONS REMEMBER YOUR ASSOCIATION STAFF CAN CALL US TO HELP EXPLAIN THE REGS AND SOLVE THE PROBLEMS WE ALL WANT TO HELP CERT AND MEDICAL INTEGRITY CONTRACTORS CERT Contractors Livanta amp Advanced Med Ask for only a single chart or case Purpose to review the reviewers If denied money must be returned Appeals possible if you disagree ZPIC Zone Program Integrity Contractors CalBisc SafeGuard Systems in J 1 Potential fraud or abuse cases Respond promptly get all i
3. nd track EDI Registration Required to get Endeavor Hours of operation nearly 24 7 Exception for maintenance CMS required downtime Information tutorials and user manual available J E URL to get more information https med noridianmedicare com web jeb topics en deavor jsessionid 47398DB81B877707CD2B21A1D2 314C38 April 2014 noiidian Recent amp Future Practica Medicare Advantage Plans will continue HMO Medicare and Private PPO EPO or Other Variations of Practice Various Risk Sharing Practices Foundations Medi Medi Dual Demonstrations Contracts with Hospitals and Universities Solo to Small to Medium Group Practices Large Multispecialty Group Practice Rising Accountable Care Organization Starting Concierge Practices Patient Contracts Insurance amp Medicare Opt Out Cash Only Federal or State Demonstrations ongoing Fee For Service Medicare amp FFS Insurance pope will continue they are definitely not yet ea TIPS FOR OFFICE MANAGERS 1 I w WEARS We H tes IV PATNA Consider possible efficiency changes p Age and practice style of physicians More office based services Be on top of billing coding appeals Beon top of overhead amp other costs You may have set fees as Medicare You may have risk sharing contracts Which services make sense in your office Strategic alliances may be good Check with healthcare attorneys Beware of con
4. nfo may be misunderstanding with patient Y mWFyIIan RECOVERY AUDITORS FORMALLY CALLED RACS HDI HealthDatalnsights for 1 Reviews old paid claims up to 5 years from date of claims Reviews medical necessity Reviews proper coding Paid a of what it brings in Look at medical necessity amp incorrect coding for over and under payment in claims already paid Can appeal denials several levels MAC QIC ALJ Judicial Council Etc RESPONDING TO ANY dan REQUEST FOR RECORDS Have a set office process for dealing with all ADRs Additional Record Requests Have one individual responsible for sending all records as part of the set office process Experienced office person or clinical person or both Have a check off sheet that involves Legibility can add typed printed addendum Correct name date physician listed in request Signature signature sheet or attestation if needed Correct address to send records Timeliness of records being sent Know how and where to get hospital records Send by certified mail or equivalent Healthcare Solutions APPEALS PROC ESS Initial Determination from Palmetto GBA 1 Redetermination from Palmetto GBA 1 Qualified Independent Contractor QIC 1 Administrative Law Judge ALJ 130 Department Appeals Board DAB 1340 Federal Court noiidian u APPEALS PROCESS Time frames for next level
5. noiidian Healthcare Solutions MANAGING MEDICARE IN 2014 Fighting Back Managing Claims California Orthopaedic Association May 30 2014 Noridan Healthcare Solutions LLC Healthcare System Changing Current orthopedic practices are evolving Only thing constant is change gradual inevitable Care from single doctor to team of doctors Solo to single amp multispecialty groups alone or aligned New 3 letter words ACO VBP NPP ACA etc Use of physician extenders NPP different business plans Salaried practices professional management practice bonuses risk sharing arrangements Alternate delivery system trials involve orthopedics Technology driven but problematic Gradual but definite transition over next few years for all concerned ortho offices groups billing and coding Physician offices need multiple new skills coding contracting IT amp computer legal financial technical plus keeping up to date with clinical matters and insurance challenges doctors can t do it all by themselves Oc TECHNICAL DENIALS ARE DOCUMENTATION FAILURES Missing or illegible physician signature or use of a signature stamp check before sending in Missing or unsigned physician orders illegible documentation Failure to provide documentation for all dates of service requested Wrong patient wrong doctor wrong date Up to 50 denials for technical rea
6. omewhere Important to list changes in care or diagnoses Lab review should be included if records asked for in a review EHRs take time to learn and may take time away from patient there is learning curve Get me outta here noiidian RESPONDING TO MEDICAL REVIEW amp RECORD REQUESTS Lee JDE OR MEDICARE A B ADMIN CENT EASTWOOD CONTRACTORS MACs ZONE PROG INTEGRITY CONTRACTOR ZPIC CERT CONTRACTOR RECOVERY AUDITOR RA QIO Usually Hospital BUNDLING AND MEDICAL UNLIKELY EDITS MUE PRIVATE INSURANCE COMPANIES FOR MEDICARE ADVANTAGE OFFICE INSPECTOR GEN noiidian MAC REVIEWS WHO GETS REVIEWED DATA OUTLIERS UNUSUAL FREQUENCY OF VISITS UNUSUAL LEVEL OR PLACE OF SERVICE FOR PATIENT POOR DOCUMENTATION IN PROBE REVIEWS SENT TO CONTRACTOR PATIENT COMPLAINTS ABOUT DOC REPEAT FALLOUTS amp WARNINGS e POSSIBILITY OF FRAUD REPORTED PREPARE FOR REVIEWS DO 1 GET PERSONALLY INVOLVED 2 COPY ALL OFFICE FACILITY OR OTHER RECORDS REQUESTED PROGRESS THERAPY NOTES CURRENT AND EARLIER IF HELPFUL TO EXPLAIN NURSING NOTES CLINICAL OBSERVATIONS AND ANY CONSULT NOTES IF HELPFUL amp DIAGNOSTIC TESTS IF RELATED TO SERVICE CHANGE IN DX MEDS OR THE CURRENT CONDITION 3 WHEN IN DOUBT SEND MORE RATHER THAN LESS TO SUPPORT MEDICAL NECESSITY OF SERVICE i ili PREP
7. sons Office staff should prevent that from happening MEDICARE MANUAL SAYS Medicare will reimburse for all services that are reasonabl and necessary for the diagnosis and treatment of an illness or injury or to repair a damaged organ WE REVIEWERS Only the eThe only way a physician Noridian reviewer treating the can determine if patient knows something is what is reasonable and reasonable and necessary is to necessary for review the that patient complete being evaluated documentation and treated submitted yi I Healthcare Solutions Templates forms OK but must be individualized for each visit Patient name date time and ID of who documented chart Computerized notes okay if individualized but medical necessity still rules on review Require time when service time related e g face to face time If poorly legible or not properly signed we must reject the claim LOOKING AT CLAIMS No more no more Often inconsistent Sometimes incoherent Still in their infancy Doctors don t know how to use or update properly they need help Cloning is rampant noiidian LOOKING AT MORE CLAIMS Electronic Records Must be kept up to date for any visit Concurrent illness must be concurrent amp significant Decision Making visit frequency important Helpful if explained listed or documented s
8. sultants you know more than them Medicine very different now than at turn of this centurv tools practice patterns science etc Remember the good old days Thank You For C
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