12/20/2011
Today’s Agenda
Texas Speech‐Language‐Hearing Association
Business Institute Program:
Appealing Denied Claims
Appealing Denied Claims
Presented by: Janet McCarty, Private Health Plans Advisor
American Speech‐Language‐Hearing Association
Filing a Claim
Provide patient information
Provide a diagnosis using ICD‐9 codes
Provide a treatment code using CPT codes
Support code assignments with patient
Support code assignments with patient history, physician referral notes, and evaluation notes
• Obtain patient permission to supply health plan with information
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CPT Coding Procedures • Use CPT codes to describe the service or treatment. • Choose the CPT procedure code that best describes the services. • Don’t unbundle codes. • Filing a claim
• Appealing health plan denials
• Recognizing and responding to reasons for denials
• Appealing beyond the health plan: preparing for external claim review
• Improving coverage strategies
• Summary
• Resources
ICD‐9‐CM Coding • Determine a diagnosis based on test results and assign a diagnostic code.
• Assign the best, or most appropriate, diagnostic code.
• Be able to support the assigned code.
• Determine the highest level of specificity, which means using the 5th digit. • Keep in mind that 784.60, 784.61, and 784.69 are subclassifications of 784.6, so when you use those codes, you are not excluding 784.6.
Claim Denied…Now What? • If your claim is denied and you don’t agree with the decision…
– consider appealing the denial
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– make sure you have evidence to support that the claim should be paid
Example: Don’t provide an additional CPT procedural code for oral motor activities if providing speech treatment under CPT 92507 or 92526. Those codes include oral motor activities as a component of the code.
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12/20/2011
More People Are Appealing Denials
40% of appeals result in reversals
(GAO‐11‐268, Private Health Insurance‐
Data on Application and Coverage Denials, March 2011) Appealing a Denied Claim • Review the patient’s insurance policy for coverage information and determine if coverage supports payment.
• Review the explanation of benefits (EOB) for denial status and reason.
• If coverage language supports payment, write an appeal letter:
– describe the disorder, – define its medical nature, and – reference the coverage policy paragraph that shows how your treatment fits coverage criteria.
• Sample appeal letters are available at: www.asha.org/members/issues/reimbursement/private‐plans/appeals.htm Reasons For Denial • Not medically necessary
• Treatment is investigational
• Not a covered service
Denial: Not Medically Necessary • Local public school provides treatment
• Treatment is educational
• Treatment is developmental in nature
• Rehabilitation is covered; not habilitation
Not Medically Necessary • Speech‐language pathology and audiology services must be viewed as treatment of impairments, and not as a quality of life issue. • Treating an individual
Treating an individual’ss speech‐language, speech language
hearing, or swallowing disorder improves health status, and therefore, is medically necessary.
Medical Necessity • Definition is often vague:
“There are almost as many definitions of medical necessity as there are payors, laws, and courts to interpret them ” and courts to interpret them.
Nancy W. Miller, Esq
Physician’s News Digest, August 2002
• Each health plan defines medical necessity
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Medical Necessity Medical necessity disputes had the highest rate of overturn, at 52%,
according to one study.
(Journal of the American Medical Association; February 2003)
Medical Necessity: Defined • Medicare defines medical necessity as: “a service that is reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve g
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the functioning of a malformed body member.” The service must be provided within generally acceptable professional medical standards.
Why Speech‐Language and Audiology Services Meet the Definition of Medical Necessity •
These services are medically necessary to treat speech‐language, swallowing, hearing, and balance disorders, many of which have a neurological basis and result from injury, illness, or disease. •
Medical necessity takes into consideration whether a service is essential and appropriate to the diagnosis and/or treatment of disease or injury.
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Stedman’s Medical Dictionary, 24th Edition, defines illness and disease as “a disorder of body functions”. Loss of hearing, impaired speech and language, and swallowing difficulties all reflect a loss of body functions and services to treat such impairments must be regarded as meeting medical necessity.
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See ASHA’s document on medical necessity: Denial: Treatment is Investigational g
www.asha.org/uploadedFiles/practice/reimbursement/private‐plans/mednecfifinal3.pdf Treatment is Investigational …a Recent Change in Policy Case Study: Appealing a Cognitive Rehabilitation Denial Because Treatment Is “Investigational”
• BCBSA’s TEC report on cognitive rehabilitation (2008 update) was recently removed (2011) from the company’s public website, without a revised version in its place This may signal a
revised version in its place. This may signal a change in BCBSA policy on coverage of cognitive rehab and clinicians may be better positioned to negotiate for improved coverage. • BlueCross
BlueCross BlueShield Association (BCBSA) BlueShield Association (BCBSA)
Technology Evaluation Center issued a report in Dec. 2002, stating cognitive rehab services were “investigational” and therefore not covered. Other independent BCBS’s adopted this policy.
However…….
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More News…..
Institute of Medicine (IOM) Report on Cognitive Rehabilitation Therapy:
The Institute of Medicine (IOM) issued a report , g
in October 2011 titled, Cognitive Rehabilitation Therapy for Traumatic Brain Injury. The IOM study supports the continued use of cognitive rehabilitation therapy (CRT) for individuals with traumatic brain injury (TBI). However….. IOM Report on Cognitive Rehab
Evidence from studies demonstrated effectiveness of CRT in the following three areas:
• Restorative strategies for language and social communication • Internal compensatory strategies for memory l
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• External compensatory strategies for memory Immediate treatment benefits were found in these areas in adults with moderate–severe TBI in the chronic recovery phase.
What prompted the IOM report?
• The U.S. Department of Defense (DoD) is seeking effective ways to address the rising incidence of TBI among military service members. members
• The DoD commissioned the IOM to conduct a comprehensive evaluation of the effectiveness of CRT for adults with TBI. IOM Report on Cognitive Rehab
Q. Media stories have reported that the IOM report shows "insufficient evidence" for CRT. Does that mean CRT has been shown to be ineffective? A. No. The report emphasizes that "...the committee supports the ongoing application of CRT interventions for individuals with cognitive and behavioral deficits due to TBI" (p. S–9).
What does "insufficient evidence" mean?
• Insufficient or limited evidence may mean that studies:
1) have not been conducted; 2) are not high enough quality to draw hi h
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conclusions about outcomes; or 3) have not addressed specific areas of CRT.
Back to the Case Study and Challenging a Health Plan • ASHA provides support for cognitive rehab (i.e., NOMS data, letters to BCBS)
• Treatment efficacy reports
• Medicare recognizes SLP’s role
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• NIH consensus statement supports cognitive rehab
• Recent independent review of denial in Montana supports cognitive rehab
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ASHA NOMs Functional gains were demonstrated by:
• 81% of patients treated for memory
• 82% of patients treated for attention
• 83% of patients treated for pragmatics
• 80% of patients treated for problem solving
NIH Support • Cognitive rehab is endorsed by the National Institutes of Health (NIH) consensus panel, which notes existing studies that support this treatment even though research in this area
treatment, even though research in this area is “exceedingly difficult to conduct.”
Research Supports Cognitive Rehab • In an article entitled, “Evidence‐based Cognitive Rehab: Updated Review of the Literature From 1998‐2002,” published in Archives of Physical Medicine & Rehabilitation
(Aug. 2005), the authors report “substantial evidence to support cognitive‐linguistic therapies for people with TBI or stroke.”
• A recent Institute of Medicine (IOM) report on cognitive rehab (2011) provides some support.
Support from U.S. Dept. of Defense & Dept. of Veterans Administration • Together form the Defense & Veterans Brain Injury Center (DVBIC)
• DVBIC actively engaged in innovative/cutting edge rehab of brain injured veterans
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• Conducts clinical research
• Brain injury becoming “signature wound of Iraq war”
Why Is Research Lacking for Cognitive Rehab? • Only controlled research can sort out the impact of treatment vs. spontaneous recovery, but it is complex and costly
It is a challenge to define the “active
active • It is a challenge to define the ingredients” of an interactive therapy provided by a clinician and the most appropriate control or comparison condition
• Gathering a sufficient number of patients with similar cognitive characteristics is difficult
However….. The absence of firm efficacy data is not evidence of the ineffectiveness of cognitive rehab. John Whyte, MD, PhD, “Promoting Research in Cognitive Neuroscience and Cognitive Rehabilitation,” Health Policy Newsletter, Vol. 18, #3, Sept. 2005. 5
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Cognitive Rehab Denial Overturned After a year of denials and appeals, an independent reviewer concurred with ASHA’s position and required BCBS of Montana to pay
position and required BCBS of Montana to pay for patient’s treatment.
Health Plan Says: Get Speech Therapy from the Local Public Schools Q.
Can a health plan say this?
A. Probably. Health plans often have a government agency exclusion clause in the contract. If a state/federal government t t If t t /f d l
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agency provides the needed treatment (schools), then that treatment is excluded from coverage.
Denial: Treatment is Educational • Refer back to the medical necessity arguments. Denial: Treatment is Educational • Respond to health plan denial noting that the services are not educational, but provided for a health‐related or medical condition, and are ,
medically necessary. • SLP services are recognized as health care services by Medicare, Medicaid, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Denial: Treatment is Developmental in Nature Denial: Treatment is Developmental in Nature p
• Plans may deny speech‐language treatment services because they consider the problem to be developmental. Your response:
– Link the communication disorder to a medical diagnosis when appropriate
– Use ICD‐9 diagnostic codes
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Denial: Rehabilitation is Covered; Not Habilitation Denial: Rehabilitation is Covered; Not Habilitation • Health plans will cover rehabilitation, but not habilitation. Plans cover lost abilities.
– Point out that young children needing therapeutic medical rehabilitation services because of illness, injury or disease should have such services covered
injury, or disease should have such services covered. – The requirement that one must first possess an ability and then lose it does not allow for the medically‐related therapy needs of infants and young children. – Rehabilitative services for young children should not be so restricted. Habilitation as an Essential Benefit
The Patient Protection & Affordable Care Act (
(ACA) specifies “essential health benefits,” )
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including rehabilitation and habilitation.
Habilitation Defined
Habilitation is defined as: Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’tt walking or talking at therapy for a child who isn
walking or talking at
the expected age. These services may include physical and occupational therapy, speech‐
language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Appealing Beyond the Health Plan: External Claim Review Preparing for External Claim Review
• Consider external claim review (independent review) after exhausting all appeal levels of health plan.
• If a patient prevails at the external claim review level, health plans must pay for the treatment, and a precedent is established.
• 42 states have an external review process
• Go to www.kff.org/consumerguide to get information about each state’s procedure and contact points.
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Strategies for Improving Coverage • Appeal claims when appropriate
• Consumer advocacy
• Legislative efforts (mandates)
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• Work with your ASHA STAR rep (State Advocates for Reimbursement)
• Be active in health care reform (federal and state level) Summary: Appeal a Claim When Appropriate • Does coverage support payment?
– Review the patient’s insurance policy for coverage information. • Can you counter?
– Review the explanation of benefits (EOB) for denial status and reason. – Be able to support code assignments with patient history, physician referral notes, and evaluation notes.
Useful Resources Q & A
1) ASHA’s Billing and Reimbursement website: www.asha.org/members/issues/reimbursement/
– Coding for Reimbursement
• Questions?
– Private Health Plans
– Medicare
– Medicaid • Appeal Stories to Share?
2) ASHA’s SLP Medical Review Guidelines: www.asha.org/uploadedFiles/SLP‐Medical‐Review‐Guidelines.pdf
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