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BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE
National Physician Advisor ConferenceNPAC2019
Putting an Octopus in a String Bag:
Jeannine Z Engel, MDAssociate Professor of Medicine
University of Utah
Translating medical necessity from payer policies to providers and patient care
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• Review Payer definitions of medical necessity
• Understand how Medical Necessity can be translated into policies for payers
• Using an LCD example, outline processes that a Physician Advisor could employ to minimize denials
Learning Objectives
Denial
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•Medicare.gov• Health care services or supplies needed to diagnose or
treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine
Medical Necessity: CMS
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• CMS.gov glossary• Services or supplies that: are proper and needed for the
diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and aren't mainly for the convenience of you or your doctor.
Medical Necessity: CMS
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Medical Necessity; Florida Medicaid Provider Manual
1. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;
2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs;
3. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;
4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and
5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.
In accordance with 42 CFR 440.230, each medically necessary service must be sufficient in amount, duration and scope to reasonably achieve its purpose.
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• What you should do, not what you can do
• What your patient needs today, no more and no less
Medical Necessity: Dr. Engel
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• LCD or NCD• If there is an NCD and/or LCD related to a particular item or service, the
NCD/LCD only defines the Medicare coding for that specific item or service that establishes medical necessity, regardless of the existence of other guidelines
• (Noridian Medicare Website)
• Contracting
Medically Necessary and Payment?
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• Medicare Program Integrity Manual Ch3:• Medical record review, for the purpose of determining medical necessity,
requires a licensed medical professional to use clinical review judgment to evaluate medical record documentation.
• Clinical review judgment does not replace poor or inadequate medical records. Clinical review judgment by definition is not a process that MACs, CERT, RACs and ZPICs/UPICs/UPICs can use to override, supersede or disregard a policy requirement. Policies include laws, regulations, the CMS’ rulings, manual instructions, MAC policy articles attached to an LCD or listed in the Medicare Coverage Database, national coverage decisions, and local coverage determinations.
Reviews or Appeals for Medical Necessity?
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How do Payers Translate Medical Necessity to Policy?
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• No LCD/NCD, but “documentation requirements”
• Medical Necessity: History and Physical • Duration/character/location/radiation of pain• Activity of daily living (ADL) limitations• Physical examination
• Evidence/support of prior conservative treatment measure(s) attempted*
• Imaging reports pertinent to performed procedure
• Operative report(s)
• Outpatient records before, during and after the procedure that support the medical necessity of performed procedures
*Note: physician statement that conservative treatment measures were completed is not supportive in and by itself; contractors do require the documentation of these measures.
Articles: Documentation Requirements- Spinal Fusion
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53975&ver=4&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Utah&KeyWord=spinal+fusion&KeyWordLookUp=Title&KeyWordSearchType=And&from2=viewtechassess.asp&where=index&tid=41&bc=gAAAACAAAAAA&
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• The most common reason for denial of SPINAL FUSION services is lack of specific information regarding conservative treatment measures which were attempted and failed prior to surgery. The statement "failed conservative/outpatient treatment" is not sufficient evidence of medical necessity
• Conservative treatment modalities include but are not limited to:
Medical Necessity: Spinal Fusion
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53975&ver=4&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Utah&KeyWord=spinal+fusion&KeyWordLookUp=Title&KeyWordSearchType=And&from2=viewtechassess.asp&where=index&tid=41&bc=gAAAACAAAAAA&
Physical TherapyOccupational TherapyJoint Injections/Epidural InjectionsAnti-inflammatory/Analgesic medications
Assistive device useActivity modificationExercise
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• Acupuncture for Chronic Low Back Pain
• Opened 1/15/19
• In response to opioid crisis
• CMS is opening this national coverage analysis (NCA) to complete a thorough review of the evidence to determine if acupuncture for CLBP is reasonable and necessary under the Medicare program. CMS is soliciting public comment on this topic
National Coverage Analysis (CMS)
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• Pre-authorization
• Some will have practice guidelines or expectations
MA plans and Commercial
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Medical Necessity and the Physician Advisor
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• External audit (MAC, RAC, QIO, ZPIC, SMRC, other)
• Internal audit
• Data analysis
• Internal QI/QA project or process
• Concern raised by internal team-member• Billing• Office manager• Nurse/physician/other provider
• Concern raised by patient or family member
PA involvement may be triggered by
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• Facet Joint and Median Branch Block (MBB) Injections
• UT service specific probe May 2014; 91 claims reviewed, pre-payment• 75 denied across the state.
• University of Utah: 12 claims, 7 denied, triggered a site specific probe November 2014
• Part A audit- facility dollars at risk, professional fees not reviewed
What’s a PA to do? A case study
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• Pre-payment audit
• Records requested
• Initial determination by MAC
• if denied, appeal to and redetermination by MAC
The process- reactive
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• Direct involvement OR review/supervise others:• Distill LCD/NCD
• Review records prior to sending for completeness
• Communicate with providers/departments
• Communicate with review teams- be the point person
• Think “SYSTEM”- this is the role of PA
The process- PA involvement?
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• Where and by whom is procedure being performed?• data pull?
• Must decide on your denominator: FFS Medicare only? All patients?
• Consider dollars at risk to prioritize resources
• Review LCD in detail and translate/distill/simplify• Consider making a checklist- for you and others
• Enlist the providers or others to assist you- relationships
• Communicate with the primary reviewer or contact person at your MAC- relationship is EVERYTHING
The SYSTEM- PA involvement
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• Review the audit process start to finish- PA will have insights at many points
• Wait for audit results vs review services prior?
• Look for denial themes
• Present to provider groups• Find you allies- there will always be one or two• Engage them to make documentation changes• Ask for help to understand where missing documentation might be hiding• Cut your losses if low dollar or low volume procedure (ROI v righteous
indignation)
• FOLLOW UP: internal audit or review
The SYSTEM- PA involvement
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Facet Joint Injection or Median Branch Block
Background
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• 3 months moderate to severe pain• With functional impairment• Not responding to conservative measures
• Pain is predominately axial• Not associated with radiculopathy or neurogenic claudication (except
facet synovial cyst)
• There is no non-facet pathology that could explain the source of pain such as tumor, infection, fracture
• Clinical assessment implicates the facet joint as the putative source of pain
Facet and MBB LCD: distilled INDICATIONS
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• Complete initial evaluation with focused MSK exam and summary of pertinent diagnostic tests and procedures must be completed
• Legible procedure note including pre and post-pain
• IA injection volume 1 mL for cervical; 2 mL for lumbar including contrast
• MBB volume limited to 0.5 mL per MB nerve for diagnostic and 2.0 mL for therapeutic
• PER SESSION, No more than • 100 mg triamcinolone or methylprednisolone • 15 mg of betamethasone or dexamethasone
Distilled PROCEDURE requirements
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• Pain documentation in scanned documents or in telephone documentation
• ADL and functional assessments in scanned documents
• Reviewing and uploading scanned documents is a manual process in EPIC
• The LCD requirements for some procedures require information from previous procedures.
Challenges: sending the records
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• Procedure performed by multiple specialties• Intervention Radiology
• Pain/Anesthesia
• Ortho-spine (one provider)
• PM&R (the main group)
• Complex anatomy for coding• Injection of MBB at “2 levels” is treating a single level facet joint.
• Complex LCD with multiple requirements• “there are simply too many notes…” (Emperor Joseph II, from “Amadeus”)
Challenges
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• Early denials due to lack of certain medical record documentation
• Functional assessments; pain scores- in scanned documents
• Not part of usual record pulls
• “you only know what you know”
Lessons learned and outcome
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• Coders are not always well educated- this is NOT their fault
• Complex anatomy; facet joints are bilateral in the spine
• This was remedied with local education and continued review by coding supervisors
Lessons Learned and outcome
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• Reviewers are not always well educated- this is NOT their fault• “radiculopathy”- many assumptions made by reviewers, required
escalation to CMD and/or re-review at MAC to avoid QIC appeals
• Redetermination denial for: “the records indicate pain was associated with neurogenic claudication, which is not an indication for the procedure as noted in the LCD.”
• As mentioned in my appeal letter, the words “neurogenic claudication” are not located in any of the medical records for this patient. The medical reviewers are making a diagnostic leap, and assigning a diagnosis which is not valid, and not supported by the MRI imaging or the patient’s physical exam findings.
Lessons Learned and outcome
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OPPORTUNITIES TO EDUCATE!
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• Early communication w redetermination team at MAC
• Frequent emails and/or phone calls to request re-review of denials when reviewers did not take into account the appeal information, or were flat out wrong
• Assumed posture of educator, rather than outraged consumer. Presented facts, not story.
• Outcome: multiple denied claims upheld at redetermination were overturned based on this “relook.”
Intervention and outcome
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• Physicians, generally, want to do better
• Presented to PM&R group
• They discussed process changes that they could embrace
• Pain/Anesthesia group- met w clinical leader, they developed documentation template to capture needed elements.
• I developed a checklist, but…
Lessons learned
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• After initial audit, facility billing group made decision to review FFS medicare claims prior to billing, and apply GZ modifier if appropriate
• When uncertain, PA asked to review
• To consider: who is the customer?
• What is at risk?
Lessons learned
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• Provider specific probe closed in September 2015
• 90 claims requested• 83 closed
• 8 withdrawn once probe closed (prior to review by MAC)
• 53 paid
• 10 accepted decision- complete or partial denial and/or coding error
• 12 overturned after initial denial (either at redetermination or re-review)
• 3 claims overturned at QIC
• 4 claims at ALJ
Where we stand
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• Follow up
• Reactive v Proactive
• QI/QA projects- this is my unicorn
• Facility v professional revenues
• Skating to the puck • DATA- but what data?
What could we do better?
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1. Review Payer definitions of medical necessity
2. Understand how Medical Necessity can be translated into policies for payers
3. Using an LCD example, outline processes that a Physician Advisor could employ to minimize denials
• facilitate change
• improve processes
• de-silo communication
• bring peace and joy to the land
Let’s review
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• Who is your customer?
• What problem are you trying to solve?• Is there really a problem?
• Is this worth the time and/or resources?
• Are YOU the right person to do the work?
• Can you facilitate a PROCESS change to avoid pitfalls in the future?
Physician Advisors: System Thinkers
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• Putting an Octopus in a String Bag
• Dressing children, especially small children, is not as easy as it appears from a distance. To become really expert, buy an octopus and a string bag. Attempt to put the octopus in the string bag so that none of the arms hang out. Time limit: all morning.
The right title?
• Putting an Octopus in a String Bag
• Affecting change as a PA, is not as easy as it appears from a distance. To become really expert, buy an octopus and a string bag. Attempt to put the octopus in the string bag so that none of the arms hang out.
• Time limit: your entire career.
