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

Home

Previous

Next

Help

I. SO, YOU HAVE A DENIAL. NOW WHAT?

Home

Previous

Next

Help

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.

Home

Previous

Next

Help

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:

Home

Previous

Next

Help

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

Home

Previous

Next

Help

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.

Home

Previous

Next

Help

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.

Home

Previous

Next

Help

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

Home

Previous

Next

Help

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)

Home

Previous

Next

Help

EX. #4: BABY BOY “WHEEZLY” (KMHP)

Home

Previous

Next

Help

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

Home

Previous

Next

Help

• 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

Home

Previous

Next

Help

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?

Home

Previous

Next

Help

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.

Home

Previous

Next

Help

“I just got one last thing, I urge all of you, all of you, to enjoy your life, the precious moments you have. To spend each day with some laughter and some thought, to get you're emotions going. To be enthusiastic every day and as Ralph Waldo Emerson said, "Nothing great could be accomplished without enthusiasm," to keep your dreams alive in spite of problems whatever you have. The ability to be able to work hard for your dreams to come true, to become a reality.”

The above are quotes from the Jimmy V Foundation for Cancer Research. It's motto is "Don't give up, don't ever give up."

“It’s important to know where you are. How do you go from where you are to where you want to be? I think you have to have an

enthusiasm for life. You have to have a dream, a goal. You have to be willing to work for it.”