By Jeanie Davis

Too often, a patient’s claim for post-acute care is denied for reasons that are entirely preventable, says Janeen Foreman, corporate director of case management for LifeCare Management Services based in Dallas/Fort Worth.

This transition may include either rehabilitation or palliative services in a facility, ongoing outpatient therapy, or care provided at home. These authorizations are scrutinized closely by both payers and regulatory bodies, so it is critical that hospital case managers know how to avoid denials, Foreman explains.

“The major problem: People don’t understand the contractual agreement with the insurance company,” she explains. “Whatever the stipulations are, you’ve got to follow them.”

Questions to consider include:

  • What does the contract say is necessary?
  • Do you have to notify on admission or prior to admission?
  • Is there a 24-hour window for notification?
  • If the procedure is prescheduled, does the patient have the medical tests necessary for that procedure?
  • Has the patient verified approvals with the physician’s office?

“To stop denials, you have to make sure you’re meeting contractual obligations,” Foreman says. “It’s all about knowing your contract and making sure you meet all the stipulations.”

Has clinical information been documented by all disciplines? Does it support the level of care the patient is receiving? Is ICU care necessary? Does the patient need an ICU-level nurse and constant monitoring?

“Each hospital has defined what qualifies a patient for that level of care,” Foreman says. “If you’re not meeting it, is the patient not sick enough for that level of care — or is it not being documented properly?”

Does the physician and staff documentation support the level of care the patient is receiving? “If the ICU standard is vital signs every two hours and it’s being done every four hours, that’s a problem,” Foreman explains. “If the doctor is saying the patient is stable and we can discharge him home in a day, do they still need ICU-level of care? Could he be moved to a lower care unit?”

Review Patient Documentation

The patient’s medical record is the focus for all this critical information. “Attention to detail is key,” says Foreman. “You also have to know what criteria you’re using to measure patient status. We anticipate patients at a specific level will need a certain level of care. If patients don’t meet those criteria as documented in the record, that’s a problem.”

When an authorization or claim is denied, it is critical to follow a specific appeal protocol.

Questions that must be addressed include:

  • Is this a Medicare denial?
  • Which payer is denying?
  • Is it a complete denial, or a partial denial?
  • Is it a denial because the insurance company says the patient should have been in a different level of care?

If the diagnosis-related group (DRG) has changed, a denial must be appealed.

“If the agreement carves out days for services but the patient’s hospitalization has been longer, the insurance company won’t pay for those days,” says Foreman. “If the patient is assigned to a specialty bed but the insurance company is not notified, there might be denial.”

Types of Denials

The appeal should be made through utilization review or case management — whoever is updating the insurance company, she adds. “The critical factor is open line of communication between you and the insurance companies.”

The type of denial is an important component. Administrative denial occurs when contract terms are not followed. A “not medically necessary” denial can be made for a variety of reasons — often because the physician skipped a step, like a diagnostic test.

An experimental or investigational procedure will not be covered. Mental health services might not be covered.

The patient might not be eligible for certain services. For example, bariatric surgery involves a very strict protocol for approval. Insurance companies refuse to cover this if there is no preauthorization or precertification.

The billing time window also is critical. If the filing is not prompt, or if there is an error in billing, the claim will be denied. Insurance companies will conduct a chart-to-charge audit, looking at whether charges match the documentation — even down to medication doses.

If a denial occurs, the appeal must be planned very carefully, says Foreman. “First, remember that the insurance company’s case manager hasn’t seen your patient.”

Review documentation to ensure accurate descriptions and adequate details about each patient and illness. The team’s documentation — what is in the patient’s record and what is not — can substantiate the appeal, says Foreman. Or, it can make an appeal impossible.

“If the medical record is rich with clinical documentation, and clearly written, your case will be good,” she explains.

The next step is to review the contract. What level of appeal are you going to make? Is it concurrent while the patient is in-house? Is it prior to admission or retrospectively after discharge? Each insurance company has several levels of appeal based on the contract.

Try Peer-to-Peer Review

Before filing an appeal, request a peer-to-peer review. “The attending physician will provide information about the patient to the insurance company’s physician,” Foreman explains. “They will talk one-on-one. Very often, the denial can get overturned there because they understand each other. This can clear up the miscommunication immediately.”

Ensure that the physician is prepared for success, Foreman advises. “Help him or her know what’s going on, why the case was denied, and what information has already been provided to the insurance company.”

Take the following steps to prepare the peer physician:

• Provide the peer physician with a brief summary of the medical history, the current problems, and the proposed treatment plan;

• Tell the peer physician what conservative treatments were used, including medications and dosages;

• Outline specific details about why this patient needs this care for this specific condition, why inpatient care is necessary, and what length of time is required for the treatment (the physician can express this last point as “based on my experience, this is expected”).

Also, prepare the physician for what not to say, says Foreman. “You don’t want any impassioned pleas; instead, talk about outcomes and evidence. You also don’t want them to agree with a watch-and-see approach. That’s viewed as withdrawal of referral for admission.”

There also should be no talk about payment levels or amounts, she adds. “You don’t want the physician to agree that the hospital will pay. You don’t want the physician to get involved with specific individuals’ considerations. The insurance companies have policies and procedures that must be followed, period.”

Keep the discussion focused on the patient, she advises. “If the doctor doesn’t agree with the peer’s decision, tell them in the phone call, ‘I don’t agree,’ and tell them their opinion is being recorded in the patient’s record so you can appeal again.”

Nearly 75% of denials can be overturned with these methods, Foreman says.

For 100% approval, “do it right in the first place,” Foreman advises. “Get everything lined up, including the documentation, and you are pretty much guaranteed of meeting the contractual obligations and getting paid.”

The bottom line is: “It’s really about the doctor stating what’s wrong with the patient, progression of the care, the patient is getting better, moving them forward, planning their discharge on admission, still looking at the end date, when the treatment will be complete.”

In getting the patient approved for post-acute care, the focus must be on medical necessity of the next level of care, whether it is rehabilitation, skilled nursing, or long-term acute care.

The physician plays a key role, as does case management. The coding has to line up with what the physician prescribed. If the physician does not document completely what is happening to the patient — if DRGs are not what the physician anticipated — that is when denials occur.

If the physician lists a DRG for respiratory failure, but the patient ends up with a COPD DRG (that was not clearly documented), there can be a reduction of payment, says Foreman. “The resource consumption may be different than what’s supported by the DRG.”

Documentation is the key to approvals, and all team members — including the physician — must fulfill their role. As the adage goes, “If you didn’t document it, it wasn’t done.”

“The most important factor in avoiding denials is to put the patient in the correct status. Then it is crucial that the documentation supports that status,” advises Erica E. Remer, MD, FACEP, CCDS, an expert in clinical documentation. In describing the patient’s status, the physician must “tell the story, and tell the truth.”

“The physician needs to detail severity, acuity, include relevant comorbidities, and specify linkage — sepsis due to aspiration pneumonia with acute hypoxic respiratory failure and metabolic encephalopathy,” Remer explains. “Not only does it change the coding but it explains your thought process and actions taken.”

Remer also advises physicians to integrate Interqual or MCG terminology (such as “hemodynamic instability” or “intractable pain”) into their documentation, but remember those are meant to be guidelines for non-providers to judge quality of medical care, not clinical criteria. “Don’t exaggerate how sick the patient is; just make sure your words are appropriate for the picture you’ve painted.”