R. Phillip Baker, MD, FACOGMedical Director Case Management and Physician Advisor

Self Regional HealthcareBoard of Directors American College of Physician Advisors

I have no conflicts of interest in this presentation and any thoughts or opinions expressed are mine alone and do not necessarily represent any organization I am affiliated with.

Understand Medicare Advantage as a Commercial Payer

Know the difference between contracted versus non-contracted interaction with the MA Plans

Be able to implement the latest in appeals strategies for MA Plans

The implications of developing relationships with Plan Medical Directors

Value added for Physician Advisors doing the Peer to Peer discussions

• Founding and Managing partner Piedmont Physicians for Women an OB/GYN private practice 1982-2014

• President, United Physicians Care, a six county IPA 1995-2018

• Chairman of the Board, Upper Savannah Health Services, A PHO with our IPA and four hospitals. 1997-2018

• Co-Chair Finance Committee, Vice Chair Local Steering Committee, Post Acute Care Utilization Committee, and serve on the Compliance Committee for Prisma Upstate a clinically integrated network 2015-present

• Medical Director Case Management and Physician Advisor Self Regional Healthcare 2014-present

• Serve on multiple committees at the South Carolina Hospital Association

• Board of Directors American College of Physician Advisors 2017-present

Medicare Modernization Act of 2003 formally renamed “Medicare+Choice” to Medicare Advantage Plans, aka Medicare Part C◦ Increased payments to plans led to increased enrollment

2004 CMS implements CMS-Hierarchical Condition Category (HCC) risk adjustment for Medicare Advantage

Affordable Care Act (2010)◦ Reduced payment rates for Medicare Advantage◦ Set a minimum Medical Loss Ratio (MLR) of 85% (i.e.

administrative overhead + profits cannot exceed 15%)◦ Continued growth in enrollment viewed as main method to

increase profitability, due to MLR◦ Aggressive marketing of Part C plans increasing % of Medicare

beneficiaries covered by Medicare Advantage

Expand choices into private plans with more comprehensive benefits with better coordination of care

Save Medicare money through efficiencies of managed care

However,

◦ From 1982 - 2016, annual spending for Part C enrollees greater than what would have been spent under Traditional Medicare (range 2-14%)

◦ In 2017, MedPAC estimated that MA payments averaged 104% of FFS spending (including quality bonuses and higher coding intensity)

“we conclude that the MA program is more efficient than in the past. However, some payment issues remain, related to intercountypayment equity, coding intensity, and quality measures.”

Function as Commercial Insurance

◦ Prior authorization for surgery, certain drugs and diagnostic procedures

◦ Concurrent Review based on screening criteria

◦ Usually require notification of admissions and concurrent clinical information be forwarded at specified intervals

◦ You must understand how the plan defines an inpatient

>50% of new enrollees

99% of Medicare beneficiaries have access to an MA plan

Average beneficiary has 23 plans to choose from

$233 billion paid by CMS to MA plans

Subpart C – Benefits and Beneficiary Protections

◦ 42 CFR §422.100-136

◦ Medicare Managed Care Manual, Chapter 4

Subpart E – Relationships with Providers

◦ 42 CFR §422.200-224

◦ Medicare Managed Care Manual, Chapter 6

Subpart M – Grievances, Organization Determinations and Appeals

◦ 42 CFR §422.560-634

◦ Medicare Managed Care Manual, formerly Chapter 13 (now unnamed chapter)

§ 422.101 Requirements relating to basic benefits.Except as specified in § 422.318 (for entitlement that begins or ends during a hospital stay) and § 422.320 (with respect to hospice care), each MA organization must meet the following requirements:(a) Provide coverage of, by furnishing, arranging for, or making payment for, all services that are covered by Part A and Part B of Medicare (if the enrollee is entitled to benefits under both parts) or by Medicare Part B (if entitled only under Part B) and that are available to beneficiaries residing in the plan’s service area. Services may be provided outside of the service area of the plan if the services are accessible and available to enrollees.(b) Comply with—

(1) CMS’s national coverage determinations;(2) General coverage guidelines included in original Medicare manuals and instructions

unless superseded by regulations in this part or related instructions; and(3) Written coverage decisions of local Medicare contractors with jurisdiction for claims in

the geographic area in which services are covered under the MA plan. If an MA plan covers geographic areas encompassing more than one local coverage policy area, the MA organization offering such an MA plan may elect to apply to plan enrollees in all areas uniformly the coverage policy that is the most beneficial to MA enrollees.

MA Plans receive a per member per month payment (benchmark Fee For Service risk adjusted)

The methodology for risk adjusting the per member per month payment is to complicated for this discussion

Bonus paid out each year based on “quality metrics” and Star Rating of 6% of premium dollars paid for that year

You have to know what the contract says about status determination and how they define terms

Your rights to appeal are generally outlined in the contract but frequently will be in documents referenced in the contract such as the provider manual. These documents must be reviewed prior to signing a contract. Most often standard contract only allows one level of appeal which is to the plan or to the auditor who did the review.

CMS does not grant contracted providers any appeal rights Understand how the contract impacts denials and the additional work to

get your facility paid. Historically MA Plans have significantly higher denial rates than any other payer.

What constitutes a readmission and when are they not payable as a separate admission? Does the plan have language that excludes patient non-compliance or the denials only occur if the facility through some action or inaction directly affected the readmission?

How long can a patient receive necessary hospital care in observation?

Does the plan have the unilateral right to make changes to the provider manual?

How long does the plan have to audit a case after discharge?

Does the plan follow the CMS Inpatient Only List?

Who can do the Peer to Peer Discussions?

What rules does the plan follow for DRG or Clinical Validation Audits?

◦ Verify that the plan reports the removal of severity adjusting diagnoses to CMS so that their per member per month reimbursement from CMS is not incorrectly increased.

Guidelines for use of post-acute care and what timeframe they have to give you a decision

Once the contract is signed you have little chance to get any additional changes

Physician Advisors are part of the revenue cycle team and should be involved in payment decisions from the time a beneficiary enters the facility, through:

◦ proper timely utilization of resources

◦ correct coding with appropriate documentation

◦ appropriate discharge planning and post acute care

Understanding your payer contracts is vital to protect the revenue integrity for your facility

CRAP – claims requiring additional processing

Amount of revenue involved in denials

◦ Enough to affect contract performance?

Administrative burden

◦ Tracking denials

◦ Writing appeals

◦ Reprocessing claims and delays in payment

Watch for zero dollar payments on readmission claims

Impact of involving CMS

As a Physician Advisor you are much more aware of the regulations around status reviews and what it takes to be an inpatient

The peer to peer discussion is not personal its business Do not undertake a discussion if you know the case does not

meet as an inpatient so that you have credibility with the payer Medical Directors

Get to know the people on the other end of the conversation Check the box person on the other end of the conversation Keep the discussion friendly Understand the immediate impact on revenue cycle Track you results Predetermination Discussion

Collect Contact information for each Medical Director and keep notes on how they interact with discussions

Try to establish regular communication about issues you are having with the Plan

Work with the Plan Regional Medical Directors when you are having issues to try to resolve those issues without formal appeals or reporting to CMS

Schedule onsite visits or regular phone calls with the Medical Directors and Plan representatives

Is there an overwhelming market reason

Can you get favorable terms in the contract to outweigh the backside loses

Can you track and justify the additional costs to being contracted

Does your facility really understand the implications of the contract on revenue cycle

Does the contract actually provide a profit margin

Does the plan have network adequacy in your area

§ 422.214 Special rules for services furnished by noncontract providers.

a) Services furnished by non-section 1861(u) providers.

1) Any provider (other than a provider of services as defined in section 1861(u) of the Act) that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.

2) Any statutory provisions (including penalty provisions) that apply to payment for services furnished to a beneficiary not enrolled in an MA plan also apply to the payment described in paragraph (a)(1) of this section.

b) Services furnished by section 1861(u) providers of service. Any provider of services as defined in section 1861(u) of the Act that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts (less any payments under §§ 412.105(g) and 413.76 of this chapter) that it could collect if the beneficiary were enrolled in original Medicare. (Section 412.105(g) concerns indirect medical education payment to hospitals for managed care enrollees. Section 413.76 concerns calculating payment for direct medical education costs.)

MA Plans have to follow original Medicare Regulations and Guidance for non-contracted facilities

The “Two Midnight Rule” [technically 42 CFR 412.3(d)] applies to status determinations◦ Includes following the Inpatient Only List

Must follow Original Medicare rules for readmission denials

Non-contract providers can bill MA enrollees for denied services, unless a “waiver of liability” is signed by the provider

Non-contract providers may access the 5 level appeal process on their own behalf, but must sign a “waiver of liability” if doing so

The issue of access to SNF benefits after a qualifying 3 day inpatient stay is yet to be resolved with CMS as they are treating that as a contract issue between the beneficiary and payer

Effective option particularly for non-contracted facilities This process was worked out after months of effort with Senior

Analyst at the CMS Medicare Advantage Group and communicated by email

CMS is primarily concerned about the beneficiary Facility must attempt one level of appeal with the payer to allow

them to correct the issue prior to escalation If a non-contracted facility is not allowed to follow Original

Medicare Guidelines and has appealed the situation to the plan then escalate this to CMS as a complaint.

Do not send privileged information in the complaint Contracted facility if you can demonstrate that a beneficiary is

being potentially harmed or denied services they should be entitled to by a payer’s practice this can be escalated as well (not allowing post-acute care, denying medically necessary services)

Humana MED C Contact at Medicare: Uvonda Meinholdt

Health Insurance Specialist Kansas City Regional Office Phone: 816-426-6544 FAX: 443-380-6020 Uvonda.Meinholdt@cms.hhs.gov

UHC MED C Contact at Medicare: Nicole Edwards Phone: 415-744-3672 Nicole.edwards@cms.hhs.gov

Coventry Health Care Med C/Aetna Med C Donald Marik Health Insurance Specialist Denver Regional Office Phone: 303-844-2646 Donald.Marik@cms.hhs.gov

Blue Cross Blue Shield Anthem Med C: Anne McMillan Health Insurance Specialist Chicago Regional Office Phone: 312-353-1668 Anne.McMillan@cms.hhs.gov

General CMS Contact: Melanie Xiao Health Insurance Specialist Medicare Advantage Branch Division of Medicare Health Plans Operations Centers for Medicare & Medicaid Services CMS San Francisco Regional Office 90 7th Street, 5-300 (5W) San Francisco, CA 94103-6708 Phone: 415-744-3613 FAX: 443-380-6371 melanie.xiao@cms.hhs.gov

To file policy questions:

◦ https://dpap.lmi.org/DPAPMailbox/

To file complaints for Region 4:

◦ PartCDInquiriesRO4@cms.hhs.gov

Denial after concurrent Review

HIPPA Breach

CMS 1696

Denial after concurrent review and authorization for inpatient status should not be allowed as per the Medicare Managed Care Manual, Chapter 4, Section 10.16, Medical necessity it states “If the plan approved the furnishing of a service through an advance determination of coverage, it may not deny coverage later on the basis of a lack of medical necessity.”

Lost Records with proof that they had the records delivered require the Plan to file a HIPPA breach with OCR:

We have a signed certified form that you received the records on Mr. X. Since you claim to no longer have those records in your possession, please go to the following link and file a HIPAA breach report with the OCR.

https://ocrportal.hhs.gov/ocr/breach/wizard_breach.jsf?faces-redirect=true

Please notify me when you file this report; if I do not hear from you in 5 working days, I will file the breach report on your behalf.

• Enrollee (beneficiary) appeal rights shown

• Non-contract providers may access standard payment appeal pathway if waiver of liability completed

• Anyone with formal representative authority can access full enrollee appeal rights without waiver of liability

• Note automatic forwarding to IRE if first level reconsideration upheld

• Must be accepted by all Medicare Advantage plans –cannot require a different form

• Sections 4 not applicable to Medicare Advantage because the Plan’s Evidence of Coverage dictates any cost-sharing responsibility, unchanged by this form

• Providers cannot charge a fee for representing enrollee

• Valid for 1 year, and for life of an appeal

R. Phillip Baker, MD

Medical Director Case Management and Physician Advisor

Self Regional Healthcare

Greenwood, SC

Office – 864-725-5589

Cell – 864-993-6863

Email – Roy.Baker@selfregional.org