SYNAGIS APPEALS WORKSHOP
GETTING REFERRALS OFF THE GROUND
PHILLY MEETING
DISTRICT R1D6
NOV 14, 2006
WORKSHOP OUTLINE (1 HOUR W/OPEN DISCUSSION)
I. SO, YOU HAVE A DENIAL. NOW WHAT?
II. MEDI FLIGHT PATTERNS OF DENIALS
III. WHAT TOOLS TO HAVE ON HAND
IV. WHY REFERRALS GET DENIED?
V. APPEAL LETTERS
VI. EXAMPLES OF DENIALS
VII. MEDICAL APPEAL LETTERS
VIII.BEST PRACTICES
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I. SO, YOU HAVE A DENIAL. NOW WHAT?
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I. SO, YOU HAVE A DENIAL. NOW WHAT?
OFFICE CALLS IN A PANIC, WHAT INFORMATION TO COLLECT:
A. With HIPPA Signed:1. Office contact information
a. Nurse, physician, call-back #’s.
2. Patient information
a. Name, DOB, GA , birth wt., diagnosis, risk factors, meds..
b. Why does office feel this baby met criteria?
3. Insurance / Distributer information
a. Where was it sent, faxed, triaged, denied, pending?
b. ISSUE: Is referral pending, denied, appealed?
c. Who did office speak with regarding this issue?
B. Without HIPPA Signed:1. Same as above except for:
NO NAMES!
NO patient identifying info can be shared: DOB, SS#, etc.
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RAP (Referral Appeals Process) Sheets
(THIS IS A SUGGESTION ONLY: if you find this helpful; this is one way to keep focused when an office calls with an issue)• HIPPA AGREEMENT SIGNED? YES / NO
• Practice Name: • Office Address: • Phone: Office Contact:• Distributor/Contact: • Parent(s) Name: Employer:• Insurance: Phone:• Patient(s) Name: SS#: DOB: GA:• Birth Wt: Current Wt:• Diagnosis:
Diagnosis:
School-age sibling Birth wt < 2500 g
Environmental air pollutants Crowded living conditions
Day care Multiple birth
Severe neuromuscular disease Family history of asthma
Congenital abnormality of airway• Dosed in NICU (Y/N) Where? When ?• Meds in past 6 months:• Referral Pending: Did office call distributor/ins. company, etc.? (Y/N)
ACTION:• Referral Denied: Why denied?
Did they receive denial letter? (Y/N)
Did physician/nurse call/write Med Dir. to appeal? (Y/N)
Was claim form filled out & coded properly? (Y/N)
Was prior auth received, if needed? (Y/N)
Did patient meet criteria? (Y/N)
Was correct distributor used? (Y/N)
ACTION:
NOTES:
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II. MEDI FLIGHT PATTERNS OF DENIALS
I. DENIED CLAIMS
PHYSICIAN: Writes Appeal Letter (utilize templates)
Calls Medical Director
Writes Health Plan
Requests Peer-to-Peer
Requests External Review if appeal fails
Paints Clinical Picture; esp. if outside guidelines
PARENT: Writes Health Plan
Works with Human Resources
Contacts THRIVE
II. CMM: NICU Recommendation
Obtain Letter from Specialist
III. MCAM/CAM: Collects all info
Outline what steps have already been taken
Will work on strategic plan for revising policy issues
Brings closure to reimbursement issue. & responds to CMM or BSS.
IV. GAM: May advise to file complaint w/Insurance Commission
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III. WHAT TOOLS TO HAVE ON HAND
1. Risk Compendium
2. Clinical Articles– AAP Brochure
– IMpact Trial
– Etc.
3. Red Book
4. Sample Letters
5. Advocates– Physicians, Specialists
– Parents, THRIVE
6. Others– RHMC (included
smoking cessation material in appeal process.
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IV. WHY REFERRALS GET DENIED
1. Inadequate/Illegible Documentation – (missing diagnosis, weight, DOB, ICD-9
code)
2. Clerical error by physician’s office – (missing date of request, no MD signature,
no MD name or ID number)
3. Incomplete pt ID info – (no group plan#, no SS#, missing
name/address, missing Employer
4. Contract expired before date of service– (physician’s network contract w/payer,
distributer/pharmacy contract).
5. Service rendered prior to effective date of coverage.
6. Patient is not a subscriber – (request sent to wrong plan by practice).
7. Maximum benefits have been paid for the yr./ Deductible has not been met.
– (January commences a new deductible period in most all plans).
8. Plan processing error related to coverage issue.
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V. APPEAL LETTERSINSTRUCT PHYSICIANS THAT EFFECTIVE LETTERS SHOULD:1. Indicate reason for letter & be specific with description
2. Keep brief, no more than 1-2 pages
3. Describe child’s diagnosis
4. Include a brief description & rationale for Synagis (providing documentation from Medi Medical Affairs)
5. NO FORM LETTERS (individualize; try to avoid exact templates)
6. Identify member ID numbers & group name
7. List dates medical care was rendered
8. Include name of facility & location where child received care
9. Include 2-3 relevant journal articles (no more than 3)
10. Send by certified mail with return receipt or by Fed Ex. Be sure to establish timelines for resolution & process for information exchange (ie: phone, email, fax, etc.).
11. Request written reply & to have live discussion with the Medical Director, not the pharmacist, case manager, claims person, etc.
12. Take it a step further & request review by a pediatrician or a pediatric pulmonologist
13. See attached examples of Appeal Templates & Letters
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VI. EXAMPLES OF DENIALS
I. EX. #1: BABY JANE DOE (GATEWAY)
II. EX. #2: BABY GIRL JONES (IBC)
III. EX. #3: BABY J. W. (MED PLUS)
IV. EX. #4: BABY BOY “WHEEZLY” (KMHP)
V. EX. #5: BABY GIRL MIA (ACCESS/EMPIRE)
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EX. #4: BABY BOY “WHEEZLY” (KMHP)
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EX. #4: BABY BOY “WHEEZLY” (KMHP)
MATT FAXED INFORMATION TO PHYSICIAN TO AID IN APPEALING CASE. SEE ATTACHED DOCUMENTS
• ATTN: DR. RAO
• SUBJECT: SYNAGIS APPEAL LETTER
• Contents:
• Suggestions
• Template Appeal Letter-Physician to Payer
• KMHP Prior Authorization Criteria for Synagis
• FROM: MATT HOLMS
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• A FEW ACTUAL EXAMPLES (SEE ATTACHED)– MECHANICSBURG PHYSICIAN
– ALLEGHENY GENERAL HOSPITAL – TO MED PLUS
– EASTCHESTER PEDIATRIC MEDICAL GROUP
• COMMON TEMPLATES (SEE ATTACHED)
VII. MEDICAL APPEAL LETTERS
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VIII. BEST PRACTICES1. BE PROACTIVE
– Keep call log to reference problems as they resurface– Know your SDN strengths & weaknesses
• keep ahead of offices with known denials/pendings• SDN may not reveal all denials (ie: prior auth denials).• SDN may list some denials that reflect referrals simply sent to wrong
distributer. May get approved if sent to correct distributer.
2. DOCUMENT– HIPPA, SDN contacts & resources, Office specifics– Get all sides of story; do not jump to conclusions
3. HIPPA TIP– To help with documentation, when faxing HIPPA forms to
Headquarters, scan a copy in your computer and save a scanned file on MediConnect under the appropriate customer. You & your CMM will easily be able to tell when the last HIPPA was signed.
4. HAVE YOUR BAG OF TRICKS AVAILABLE
5. PICK YOUR BATTLES (What does “every child matter” mean to you?
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VII. BEST PRACTICES
6. SUGGEST OFFICE KEEP ALL NON-APPEALED DENIALS ON FILE– Suggest to re-evaluate at each visit to determine change in clinical
status (pt having resp problems, use of bronchodilators, new risk factors present) & then re-submit.
7. KNOW WHO TO CALL AND WHEN– An MCAM may not be able to move a payer who is simply following
policy (ie: last season, Gateway was more lenient with >33 wkrs. This year, they are strictly adhering to AAP Guidelines).
8. KNOW YOUR PAYERS AND THEIR APPEAL PROCESS– Can a verbal request be given?– Or is a written request required?– Be familiar with Medical Directors and their practices. (Examples?)
9. UTILIZE SDN PARTNERSHIPS– They may have insight to payer trends or what works / doesn’t
work.
10. CREATE AUTONOMOUS SYNAGIS COORDINATORS– Don’t get in the habit of doing everything for the coordinators all
the time. You may end up creating an office whose referrals never seem to get off the ground. Use your good judgement and gently encourage.
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