Payment Strategies
2014 New Year’s Resolution: Improve Your Insurance Benefit Verification Process Kathleen D. Schaum, MS All readers’ parents have most likely taught them this proverb: An ounce of prevention is worth a pound of cure. That proverb reverberates in this author’s head when wound care professionals, providers, and/or billers call and ask about claim denials that could have been prevented. The following information details the investigative process that this author usually follows.
Medicare Fee-for-Service When the payer is Medicare fee-for-service, we determine if the Medicare Administrative Contractor (MAC) that processes their claims has an active local coverage determination (LCD)/article that pertains to that service/procedure/ separately payable product. If the MAC has not found it necessary to publish an LCD, we consider that as good news: The service/procedure/ separately payable product will be covered if the qualified healthcare professional (QHP) documents adequate medical necessity and the MAC agrees that it is medically necessary. If the MAC has found a reason to control utilization of the service/procedure/separately payable product, we obtain the LCD/article that existed on the date that the service was performed. Note: If we need an older version of the LCD/article, we can retrieve it from the archived LCDs on the Centers for Medicare & Medicaid Services coverage database: http://www.cms.gov/medicare-coverage-database/ overview-and-quick-search.aspx. Next, we read the LCD and the medical record to identify if the patient’s diagnosis is one of the covered diagnoses, if the CPT* code reported is one of the covered CPT codes, and/or if the Healthcare Common Procedure Coding System (HCPCS) code reported is one of the covered HCPCS codes. We also review the number of units reported for each service/ procedure/product code to be sure the units align with the code descriptors. Then we consider if the reported codes align with the National Correct Coding Initiative (NCCI) edits. That leads us to look at the modifiers that were/were not appended to the codes. Callers should review the documentation that is in the medical record to be sure that it matches with the documentation requirements specified in the LCD.
We often find that wound care professionals and providers did not read the LCD and/or attached article before they performed the service/procedure and/or used the product. Therefore, they may not have understood the diagnosis codes that are covered. They may not have given the patient an Advance Beneficiary Notice of Noncoverage (ABN) if they performed the procedure for a noncovered diagnosis or procedure; in some instances, ABNs are not available. Frequently, we discover that the incorrect service/procedure/product code was used on the claim or that NCCI-restricted code pairs were submitted. Amazingly, we sometimes find that the number of units that were entered into the charging system/encounter form was not the number of units that were actually submitted on the claim. In some cases, the required modifiers were not used, or modifiers were used incorrectly. Finally, when the callers review the documentation in the medical record, hopefully they will find that it clearly supports medical necessity and is solid enough to support an appeal. If the documentation falls short of the LCD/article requirements, overturning an appeal may be difficult. In addition, we may find that the business unit needs to improve its insurance benefit verification process. Verifying that the Medicare fee-for-service beneficiary has paid for their Medicare Part B benefit is only the first step. The wound care business unit must also have a process established where someone is assigned to: identify all the LCDs/articles that pertain to the work performed; review the designated MAC’s website on a monthly basis (identify any revisions to the LCDs/articles, identify any draft LCDs/articles, and identify any future effective LCDs/ articles); and print and share all LCDs/articles with the entire medical staff, clinical staff, and coding/billing staff. Every wound care stakeholder should be responsible for reading each pertinent LCD/article and for adjusting his/her documentation, ABN, and coding practices to align with the requirements of the LCD/article. Many QHPs will ask such questions as ‘‘What is an LCD?’’ ‘‘What is an ABN?’’
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. Information regarding payment is provided as a courtesy to our readers, but does not guarantee that payment will be received. Providers are responsible for case-by-case documentation and justification of medical necessity. ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
546
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Payment Strategies ‘‘Why can’t someone/the manufacturer/the consultant read
the LCDs/articles and just tell me what to do?’’ First, we must take the time to educate them about LCDs and ABNs. Then we must educate them about ‘‘why’’ they need to read the LCDs/articles. When QHPs ask this author to give them the ‘‘CliffsNotes’’ about an LCD/article, I always ask them ‘‘What part of the MAC’s directive do you not want to know about?’’ That response usually helps the QHPs come to the conclusion that the entire LCD/article is important and they should always read their MAC’s LCDs/articles. Selfeducation will help the QHP to personally know what should be documented to prove medical necessity, when to give the patient the opportunity (via an ABN) to receive a service/ procedure/product that Medicare may not cover for their particular condition, how to use compliant coding practices, and so on. While reading the LCDs/articles, the QHPs should highlight areas that they want to remember and prepare documentation templates that make sense to them.
Medicare Advantage, Private Payer, Worker’s Compensation, Medicaid When the payer is a Medicare Advantage plan, a private payer, worker’s compensation, or Medicaid, for example, we review their wound care business unit’s insurance benefit verification process. If a medical policy is available from that payer, we review the policy. We then carefully review the diagnosis code(s), CPT code(s), and/or HCPCS code(s) and number of units submitted on the claim. Finally, we review the QHPs’ documentation in the medical record. In many cases, the wound care business unit did not think about the fact that most of the wound care work they perform is considered a surgical procedure, even though it may be performed in a physician’s office or in the treatment room of a hospital-based outpatient wound care department (HOPD). Most of the contracts that physicians and HOPDs have with these payers require them to verify insurance benefits before performing surgical procedures, and separately payable products, when applicable. Unfortunately, many QHPs perform these procedures/products without verifying if they are covered benefits on the patient’s insurance plan. By now you must be asking, ‘‘How does this happen?’’ The wound care business unit may verify that the patient is indeed covered by the plan shown on his/her insurance card. However, they often do not ask about coverage for the top 10 services/ procedures/products used to manage patients with chronic wounds. When the QHP is caring for the patient, he/she does not stop and discuss needed surgical procedures with the patient and, most important, does not verify if the surgical procedures (and separately payable products) are covered and cleared by the patient’s insurance plan. If the QHP performed the procedure/used the product without insurance ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
plan clearance, he/she has already violated the contract with the payer. But what about the case where the wound care business unit called and asked if the procedure required prior authorization? Consider this: If the plan does not cover a certain procedure/ product, and the wound care business unit calls and asks if the procedure/product requires prior authorization, there is a fairly high chance of the plan saying, ‘‘No, it does not require prior authorization.’’ To prevent this miscommunication, the wound care business unit should always begin their conversation with a payer by verifying that the patient indeed has the insurance coverage, if that plan covers the service/procedure/ product for that patient’s diagnosis, and if prior authorization is required. This will prevent performing a noncovered service without discussing payment with the patient.
Five Tips for a Successful Insurance Benefit Verification Process Before 2014 begins, QHPs and providers should make a New Year’s resolution to either implement an insurance benefit verification process or improve your existing process. Here are a few tips to help you keep your resolution: 1. Identify all the wound care services/procedures/ separately payable products that are used by your wound care business unit. 2. Research all the LCDs/articles that pertain to the services/ procedures/separately payable products: Be sure every QHP, coder, and biller reads and understands the LCDs/ articles. On a monthly basis, review your MAC’s website for revised, draft, and future effective LCDs. Remember: You must verify coverage by reviewing the LCDs/articles. And, Medicare fee-for-service programs do not offer prior authorization. That is why the LCDs/articles are your Medicare fee-for-service ‘‘playbook.’’ 3. Create a process for making ABNs available to QHPs at the point of care. 4. Verify the patient’s insurance benefits before his/her scheduled appointment. 5. Check if the top 10 services/procedures/products typically used are covered on specific Medicare Advantage, private payer, worker’s compensation, Medicaid, and other plans. Also, check that the QHP and the place of service are covered by that plan. Record that information where the QHP can readily see it. If a service/procedure/product is needed by the patient, but the insurance benefit has not been checked, inform the patient that (1) your business unit will try to gain insurance clearance while the patient waits, or (2) your business unit will try to do so before the patient’s next visit.
&
*CPT is a registered trademark of the American Medical Association.
548
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
2014 New Year’s Resolution: Improve Your Insurance Benefit Verification Process Kathleen D. Schaum, MS All readers’ parents have most likely taught them this proverb: An ounce of prevention is worth a pound of cure. That proverb reverberates in this author’s head when wound care professionals, providers, and/or billers call and ask about claim denials that could have been prevented. The following information details the investigative process that this author usually follows.
Medicare Fee-for-Service When the payer is Medicare fee-for-service, we determine if the Medicare Administrative Contractor (MAC) that processes their claims has an active local coverage determination (LCD)/article that pertains to that service/procedure/ separately payable product. If the MAC has not found it necessary to publish an LCD, we consider that as good news: The service/procedure/ separately payable product will be covered if the qualified healthcare professional (QHP) documents adequate medical necessity and the MAC agrees that it is medically necessary. If the MAC has found a reason to control utilization of the service/procedure/separately payable product, we obtain the LCD/article that existed on the date that the service was performed. Note: If we need an older version of the LCD/article, we can retrieve it from the archived LCDs on the Centers for Medicare & Medicaid Services coverage database: http://www.cms.gov/medicare-coverage-database/ overview-and-quick-search.aspx. Next, we read the LCD and the medical record to identify if the patient’s diagnosis is one of the covered diagnoses, if the CPT* code reported is one of the covered CPT codes, and/or if the Healthcare Common Procedure Coding System (HCPCS) code reported is one of the covered HCPCS codes. We also review the number of units reported for each service/ procedure/product code to be sure the units align with the code descriptors. Then we consider if the reported codes align with the National Correct Coding Initiative (NCCI) edits. That leads us to look at the modifiers that were/were not appended to the codes. Callers should review the documentation that is in the medical record to be sure that it matches with the documentation requirements specified in the LCD.
We often find that wound care professionals and providers did not read the LCD and/or attached article before they performed the service/procedure and/or used the product. Therefore, they may not have understood the diagnosis codes that are covered. They may not have given the patient an Advance Beneficiary Notice of Noncoverage (ABN) if they performed the procedure for a noncovered diagnosis or procedure; in some instances, ABNs are not available. Frequently, we discover that the incorrect service/procedure/product code was used on the claim or that NCCI-restricted code pairs were submitted. Amazingly, we sometimes find that the number of units that were entered into the charging system/encounter form was not the number of units that were actually submitted on the claim. In some cases, the required modifiers were not used, or modifiers were used incorrectly. Finally, when the callers review the documentation in the medical record, hopefully they will find that it clearly supports medical necessity and is solid enough to support an appeal. If the documentation falls short of the LCD/article requirements, overturning an appeal may be difficult. In addition, we may find that the business unit needs to improve its insurance benefit verification process. Verifying that the Medicare fee-for-service beneficiary has paid for their Medicare Part B benefit is only the first step. The wound care business unit must also have a process established where someone is assigned to: identify all the LCDs/articles that pertain to the work performed; review the designated MAC’s website on a monthly basis (identify any revisions to the LCDs/articles, identify any draft LCDs/articles, and identify any future effective LCDs/ articles); and print and share all LCDs/articles with the entire medical staff, clinical staff, and coding/billing staff. Every wound care stakeholder should be responsible for reading each pertinent LCD/article and for adjusting his/her documentation, ABN, and coding practices to align with the requirements of the LCD/article. Many QHPs will ask such questions as ‘‘What is an LCD?’’ ‘‘What is an ABN?’’
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. Information regarding payment is provided as a courtesy to our readers, but does not guarantee that payment will be received. Providers are responsible for case-by-case documentation and justification of medical necessity. ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
546
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Payment Strategies ‘‘Why can’t someone/the manufacturer/the consultant read
the LCDs/articles and just tell me what to do?’’ First, we must take the time to educate them about LCDs and ABNs. Then we must educate them about ‘‘why’’ they need to read the LCDs/articles. When QHPs ask this author to give them the ‘‘CliffsNotes’’ about an LCD/article, I always ask them ‘‘What part of the MAC’s directive do you not want to know about?’’ That response usually helps the QHPs come to the conclusion that the entire LCD/article is important and they should always read their MAC’s LCDs/articles. Selfeducation will help the QHP to personally know what should be documented to prove medical necessity, when to give the patient the opportunity (via an ABN) to receive a service/ procedure/product that Medicare may not cover for their particular condition, how to use compliant coding practices, and so on. While reading the LCDs/articles, the QHPs should highlight areas that they want to remember and prepare documentation templates that make sense to them.
Medicare Advantage, Private Payer, Worker’s Compensation, Medicaid When the payer is a Medicare Advantage plan, a private payer, worker’s compensation, or Medicaid, for example, we review their wound care business unit’s insurance benefit verification process. If a medical policy is available from that payer, we review the policy. We then carefully review the diagnosis code(s), CPT code(s), and/or HCPCS code(s) and number of units submitted on the claim. Finally, we review the QHPs’ documentation in the medical record. In many cases, the wound care business unit did not think about the fact that most of the wound care work they perform is considered a surgical procedure, even though it may be performed in a physician’s office or in the treatment room of a hospital-based outpatient wound care department (HOPD). Most of the contracts that physicians and HOPDs have with these payers require them to verify insurance benefits before performing surgical procedures, and separately payable products, when applicable. Unfortunately, many QHPs perform these procedures/products without verifying if they are covered benefits on the patient’s insurance plan. By now you must be asking, ‘‘How does this happen?’’ The wound care business unit may verify that the patient is indeed covered by the plan shown on his/her insurance card. However, they often do not ask about coverage for the top 10 services/ procedures/products used to manage patients with chronic wounds. When the QHP is caring for the patient, he/she does not stop and discuss needed surgical procedures with the patient and, most important, does not verify if the surgical procedures (and separately payable products) are covered and cleared by the patient’s insurance plan. If the QHP performed the procedure/used the product without insurance ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
plan clearance, he/she has already violated the contract with the payer. But what about the case where the wound care business unit called and asked if the procedure required prior authorization? Consider this: If the plan does not cover a certain procedure/ product, and the wound care business unit calls and asks if the procedure/product requires prior authorization, there is a fairly high chance of the plan saying, ‘‘No, it does not require prior authorization.’’ To prevent this miscommunication, the wound care business unit should always begin their conversation with a payer by verifying that the patient indeed has the insurance coverage, if that plan covers the service/procedure/ product for that patient’s diagnosis, and if prior authorization is required. This will prevent performing a noncovered service without discussing payment with the patient.
Five Tips for a Successful Insurance Benefit Verification Process Before 2014 begins, QHPs and providers should make a New Year’s resolution to either implement an insurance benefit verification process or improve your existing process. Here are a few tips to help you keep your resolution: 1. Identify all the wound care services/procedures/ separately payable products that are used by your wound care business unit. 2. Research all the LCDs/articles that pertain to the services/ procedures/separately payable products: Be sure every QHP, coder, and biller reads and understands the LCDs/ articles. On a monthly basis, review your MAC’s website for revised, draft, and future effective LCDs. Remember: You must verify coverage by reviewing the LCDs/articles. And, Medicare fee-for-service programs do not offer prior authorization. That is why the LCDs/articles are your Medicare fee-for-service ‘‘playbook.’’ 3. Create a process for making ABNs available to QHPs at the point of care. 4. Verify the patient’s insurance benefits before his/her scheduled appointment. 5. Check if the top 10 services/procedures/products typically used are covered on specific Medicare Advantage, private payer, worker’s compensation, Medicaid, and other plans. Also, check that the QHP and the place of service are covered by that plan. Record that information where the QHP can readily see it. If a service/procedure/product is needed by the patient, but the insurance benefit has not been checked, inform the patient that (1) your business unit will try to gain insurance clearance while the patient waits, or (2) your business unit will try to do so before the patient’s next visit.
&
*CPT is a registered trademark of the American Medical Association.
548
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
