UPMC denial management program saves $1 million

Central department handles retrospective appeals

A multilevel denials management process generates $1 million or more in recovered revenue annually for inpatient accounts at the University of Pittsburgh Medical Center (UPMC), a larger health system with 20 medical facilities.

The hospital system's denials management process starts with the concurrent appeals conducted by the hospital case managers who can elevate the process to the attending physician or the hospital medical director. When a hospital stay is still denied, a central department handles the retrospective denials, requesting a review by an external source if necessary, says Charleeda Redman, RN, MSN, ACM, director of care management at UPMC.

The systemwide denials process was implemented in 2002 when the hospital organization installed the electronic case management system and created the centralized department to assist with care management. The appeals process model is based on the multilevel appeals process being used by one of the largest hospitals in the system.

Before the new system was implemented, case managers at other hospitals in the system managed the entire appeals process, making a concurrent appeal and following up with a retrospective appeal of denials.

"This system is much more consistent and effective. We have gained many process efficiencies by centralizing the retrospective appeal of denials," Redman says.

Redman's department has a staff of about 25 and is responsible for training and development of case management and social work care management in addition to handling retrospective inpatient and outpatient denials and appeals for medical necessity and authorization.

Hospital-based case managers are responsible for the day-to-day management of concurrent denials and use the case management software system to track their efforts.

A 'threatened' day

When the payer indicates to the care manager that it is not going to allow another acute care day, the hospital system labels it as a "threatened day."

"It's not technically a denial. The care manager notes in the software that the payer has denied a request for another acute care day or would authorize only a lower level of care," she says.

When an insurer indicates that a continued stay or admission might be denied, the nurse case manager determines why the stay is being denied and takes action to overturn it.

For example, if it's a medical necessity issue, the case manager looks for additional clinical information, such as missing laboratory values. The case manager then touches base with the physician, reports that the insurance company believes the patient could be discharged or be transferred to a lower level of care, and asks the physician if there is additional information that could justify the patient stay.

"That phone call could provide key information that the case manager could communicate to the insurance company," she says.

Getting threatened status overturned

If the additional information isn't enough to get the threatened day overturned, the case manager can escalate the case to the attending physician who can call the payer and request a peer-to-peer review.

If for any reason, the attending physician is unwilling or unable to call the insurer, the case manager refers it to the physician advisor who reviews the chart and makes the decision of whether to appeal. The physician advisor then calls the attending physician to get information about the patient and calls the payer.

If the hospital's physician representative determines that the payer is right, the case manager works with the physician to facilitate discharge to home or to a lower level of care.

The case managers document the final outcome of the concurrent appeal in the case management software.

"The software has the ability to run a report within the application to show any outstanding cases that did not have an outcome. The organization generates an e-mail report every day to the director of case management, the nursing leadership, the CEO, and the CFO in each individual hospital, listing any patients' whose continued delay has a threatened denial without a resolution," she says.

For instance, a patient may come to the emergency department with chest pain and the attending physician believes the patient needs to be admitted as an inpatient.

"Unless patients have certain clinical values, many payers will approve only admission to an observation level of care. In this case, we would enter the information as a threatened day because the physician wants to admit the patient and the payer suggests observation," she says.

If the patient is admitted and the payer doesn't agree, the hospital makes a retrospective appeal.

Redman generates monthly reports tracking whether the denial was overturned, the hospital accepted a lower level of care, or the appeal was denied. She meets regularly with the CEO, CFO, and director of case management at each hospital to review denial information.

"We look at how well we are doing, what are our payer issues, and whether the nurses and doctors are successful when they try to get denials addressed concurrently," she says.

When the hospital case managers can't get the denial overturned concurrently, Redman's department reviews the case and decides whether to take action. Two nurses in the department are responsible for reviewing the cases handled by the inpatient case managers. The nurses request the entire medical record if necessary or view it on-line.

"If the nurse feels there is enough information and criteria to support an acute care day, we file an appeal. If we can't find supportive documentation in the medical record, the physician advisor for our department reviews the information to determine if documentation can be adjusted on the back end to give us grounds for appeal," she says.

Escalation process

The first level of appeal is a written appeal from a nurse in Redman's department.

"If we are unsuccessful at the first level, we review the case with the medical director and determine if there is information to warrant a second level of appeal." All letters written at the second level of appeal come from a physician who requests a peer review hearing.

If the second level of appeal is unsuccessful, Redman's staff review the information with the medical director to determine if it would be useful to ask for an external review from a third party.

"When we ask for external review, we make sure that our contentions are supported and we are not taking unnecessary cases to that level. We don't fight everything at that level. We just ask for the external review when we believe that the care was medically necessary and appropriate," she says.

The hospital system is successful in 80% to 85% of the cases it submits for external review.

Many of the denials are overturned retrospectively because additional information was not available at the time the care was denied.

"Most of the time it is frontline communication between one nurse and another nurse. The nurse on the payer side has criteria to follow to determine if something is medically appropriately," Redman explains.

The nurses on the payer's side have to follow the payer's criteria to determine if something is medically appropriately, she points out.

"If the payer nurse questions the medical necessity of care, it has to be escalated to the physician level. If there is one piece of data that isn't available at the time, that could be a reason for the denial," she says.

For instance, the payer may determine that the patient didn't meet acute care criteria, based on the payer's criteria. When the hospital system conducts the retrospective appeal, there may be information in the medical record that shows that the care was medically necessary even though it didn't meet standard criteria, Redman says.

Sometimes the appeal was denied concurrently because the physician who reviewed the case for the payer was not an expert in the condition for which a patient was being treated, Redman says.

For instance, a physician with a background in internal medicine may conduct the concurrent review of a continued stay for a patient with a transplant-related condition.

"Most payer laws state that the second level of review must be done by a physician of similar specialty," she says.

Redman works with corporate contracting to represent case management issues in negotiating contracts with payers.

By using the case management software system, the hospital system can track payer trends across multiple hospitals and has been successful in renegotiating contracts with two major payers to address issues for denials.

For instance, many denials occur because of a delay in service on the weekend. When the contract was renegotiated it included language stating that if a patient meets InterQual criteria, the hospital will be paid for those days when test results that would affect the next level of treatment or intervention are pending. For instance, if the patient couldn't be safely discharged until the pathology results were in, the hospital would be paid for acute level of care until the results are in.

In another instance, the payer had contracts with a limited number of skilled nursing facilities in the area. The hospital system successfully negotiated that if the hospital could provide that none of their approved facilities could accept the patient, the payer would reimburse the hospital at the skilled or subacute level of care, rather than outright denying a continued stay.

(For more information, contact Charleeda Redman, e-mail: redmanca@upmc.edu.)