Embed Size (px)
Citation preview
Strategies for Post-COVID Commercial Payor Reimbursement Planning
Jonathan BuckShareholder
Los Angeles, CA
310.203.5369
June 11, 2020
David KingShareholder
Nashville, TN
615.259.1538
2
Polsinelli COVID-19 Resources
Contact
For COVID-19 legal advice across a spectrum of
issues impacting an array of industries and legal
areas, our team is available and connected
nationally and in the communities in which you
operate.
Contact us with questions at:
Polsinelli’s cross-disciplinary COVID-19 blog
provides companies tools and information needed
to effectively and lawfully protect their employees
and business.
Visit our blog:
https://www.covid19.polsinelli.com/
Blog + Resources
2
Pulled from the headlines
Covid-19 Crisis: Not Everyone is Hurting!
3
Planning for COVID-related Payor Policy
Changes and Audits
Strategies for Tackling Past Claims Backlog
Anticipating Changing Health Care Delivery
Models
Navigating Increased Regulatory Involvement in
Arrangements
Strategies for Post-COVID Commercial Reimbursement - Topics
4
Prepare for Evolving Payor Policies
Prepare for COVID-related Audits
Planning for COVID-related Payor Policy Changes and Audits
5
Prepare for Evolving Payor Policies
Push-back on reimbursement for antibody testing
Non-waiver of patient cost-sharing for treatment of Covid-19
Non-waiver of patient cost-sharing when Covid-19 is not coded as the primary
diagnosis (i.e., if the patient had sepsis)
Non-waiver of patient cost-sharing for “associated visit” when the site of the
visit is ED (adjudicating as “treatment” and not waiving cost-sharing)
Not-waiver of cost-sharing for non-specific Covid testing in early days of
pandemic
Continuing attempts to reimburse at “government” rates
Non-extension of waivers
6
Planning for COVID-related Payor Policy Changes and Audits
COVID-related Audits
Maintain evidence of payor policy changes on website/email
Explain volume of service changes
Anticipate resumption of suspended practices and requirements
What ability do providers have to limit/prevent retrospective reviews?
If preauthorization suspended, will a relaxed standard be applied on audit?
Review documentation of service during emergency
Review billing changes – coding, modifier, place of service
Planning for COVID-related Payor Policy Changes and Audits
7
Payor Contract Review
Understand your Contract Rights
Payor’s right to amend the Contract through a unilateral policy?
Utilization management policies
Quality control policies
Medical coverage policies
Cram-Down rate changes?
Right to consolidation of claims (bundling)
Track and challenge policies that breach the Contract or constitute
material changes
8
Planning for COVID-related Payor Policy Changes and Audit
Prioritize Analysis of Past Claims
Identify trended issues
Identify high-dollar claims
Identify payor policy changes affecting reimbursement
Bucket “General Denials” of lower-dollar claims
Strategies for Tackling Past Claims Backlog
9
How to Prioritize Analysis of Claims in Each Category
Deadlines
Dollars at issue
Resources needed to gather and organize claim information
Chances of success
Strength/status of relationship with various payors
Strategies for Tackling Past Claims Backlog
10
Analyze the Nature and Extent of Past Claims Issues
Run Data Analytics for Claims
Bucket Claims
Denials
Clinical
Technical
Misclassified claims
Underpayments
Rate (OON or INN)
Payor Policy Changes
Strategies for Tackling Past Claims Backlog
11
Understand Where Problem Lies to Cluster the Claims
By State
By Hospital
By Payor Class
By Payor
By Contract (commercial vs. MA vs. Medicaid)
By Denial Code
Strategies for Tackling Past Claims Backlog
12
Conduct a Payor Engagement Audit
Update assignment of benefits
Review administrative appeal process and templates
Review and update processes for responding to audits, recoupments
and offsets.
Strategies for Tackling Past Claims Backlog
13
Understand In-network Dispute Resolution Processes
Understand and initiate contractual dispute resolution procedures:
Joint Operating Committee (JOC), Contract Operating Group (COG)
Administrative Appeals
Mediation, arbitration, or litigation
Prepare demand letter to payor’s inside counsel and/or contracting partner
Consider resolution alternatives, possibly in collaboration in payor
Payors may be receptive to special projects and custom approaches
Assemble evidence in a reasonable and usable way
Avoid “data dump”
Package data in a way that is meaningful to both sides
Strategies for Tackling Past Claims Backlog
14
Special Considerations for OON Disputes
Understand rights assigned to you by your patients in your Assignment of Benefits
(both legal and equitable rights)
Important to identify misclassified claims
Especially important to identify the declared basis for misclassified or underpaid
claims
Locate and review all discussions with payors regarding any adverse determinations
(course-of-dealings, implied contract)
Understand that administrative appeal requirements still apply
Strategies for Tackling Past Claims Backlog
15
ONN Dispute Escalation
Consider that deadlines for litigation may be in the healthcare plan and
not set by statute
Attorney demand letter (in-house/outside counsel)
Mediation
Agreed Arbitration
Litigation
Going-forward Contract
Strategies for Tackling Past Claims Backlog
16
Track and Challenge Payor Policy Changes
Changes to “routine” language in contracts
Medical Necessity & Site of Service
Covered services
Who is the payor?
“Declared” broad medical policy changes
Provider manuals/reference guides
Other information incorporated into contract by reference
“Undeclared” coding edits
Strategies for Tackling Past Claims Backlog
17
Changes to Historical Delivery Patterns
Telehealth and Site of Service
Remote Patient Monitoring
Behavioral Health
Ancillary Services
Changes to non Hospital-based Providers
Revised Contracting and Reimbursement Strategy
Anticipating Changing Health Care Delivery Models
18
How will relationships and partnerships change?
Referral partners, potentially
How much more will payors get involved in providing care?
How will payors further push (or resist) changes in site of service?
Will volume be affected?
Will payor mix change?
Anticipating Changing Health Care Delivery Models
19
Long-term Covid-19 Services?
Setting up dedicated Covid-19 unit
Education, training, consulting for businesses
Employee-testing for businesses
Anticipating Changing Health Care Delivery Models
20
Anticipate greater governance role in commercial payor –
provider relationships (Ex. California A.G.: SB 977)
Consent for acquisitions and standards for approval
Impact on strategies and timing/planning
Prohibits anti-competitive contracting practices by providers
No impact on proliferation of payors acquiring medical groups
Increased downstream regulatory requirements in contracts
Medicare Advantage
Medicaid Managed Care
Navigating Increased Regulatory Involvement in Arrangements
21
22
Polsinelli COVID-19 Resources
Contact
For COVID-19 legal advice across a spectrum of
issues impacting an array of industries and legal
areas, our team is available and connected
nationally and in the communities in which you
operate.
Contact us with questions at:
Polsinelli’s cross-disciplinary COVID-19 blog
provides companies tools and information needed
to effectively and lawfully protect their employees
and business.
Visit our blog:
https://www.covid19.polsinelli.com/
Blog + Resources
22
Polsinelli PC provides this material for informational purposes only. The material provided herein is general and is not intended to be legal
advice. Nothing herein should be relied upon or used without consulting a lawyer to consider your specific circumstances, possible changes
to applicable laws, rules and regulations and other legal issues. Receipt of this material does not establish an attorney-client relationship.
Polsinelli is very proud of the results we obtain for our clients, but you should know that past results do not guarantee future results; that
every case is different and must be judged on its own merits; and that the choice of a lawyer is an important decision and should not be
based solely upon advertisements.
© 2020 Polsinelli® is a registered trademark of Polsinelli PC. Polsinelli LLP in California. Polsinelli PC (Inc.) in Florida.
polsinelli.com
