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The Wisdom of Yogi Berra in Medical Benefit Appeals

Posted on October 31, 2018 I Written By

The following is a guest blog post by Keith J. Saunders, Esq., Founder & CEO of FHAS.

“This hearing will now come to order.  For the record, today’s date is…and the following parties are present…”

I have repeated this sentence thousands of times over the past twenty three years while serving as a hearing officer for the Federal Medicare program and as an Administrative Law Judge (ALJ) for the Commonwealth of Pennsylvania Medicaid program.  Serving as an adjudicating official for medical benefit appeals can provide one with a unique perspective on human nature and the shortcomings of the medical appeals process. 

In this post, I would like to share three takeaways from my experience in order to assist you in being a successful participant in the appeals process, whether you participate from the side of the payor or appellant.

Know the medical facts.

My first piece of advice is inspired by a quote from the great New York Yankees baseball player and manager Yogi Berra: “You can observe a lot just by watching”.  Most participants in medical benefit appeals fail to perform the requisite watching.

If you are going to successfully defend or pursue your appeal, you must know the medical facts of the case. This might seem obvious, however you would be shocked to learn how many times a claim denial is appealed and it is very apparent that the parties don’t know or understand the condition of the patient, underlying the facts of their case. For medical provider appellants who are part of large health systems, the need to survey all records within your system pertaining to the subject of the appeal is critical.

For third party payers it is likewise critical to ensure that you possess a complete understanding of the condition of the patient.  I once presided over a hearing where the health insurer was challenging the necessity for the patient to have a wheelchair.  They indicated that the medical information submitted with the claims failed to indicate that the patient could not walk.   If they had performed a survey of the medical records contained within the file they would have ascertained that the patient was a bilateral AKA. For those of you who do not frequently traverse through medical records, this acronym stands for bilateral above the knee amputee; this patient had no legs.

Understand why the claim was denied.

Turning again to Yogi Berra for my second piece of advice: “You’ve got to be very careful if you don’t know where you are going because you might not get there.” In order to be an effective advocate for your position, you must thoroughly understand why a claim for reimbursement has been denied by the third party payor.  One of the most frequent bases advanced for denials in both the Medicare and Medicaid programs is the blanket catchall basis of, “a lack of medical necessity”.  This basis is utilized to deny submitted claims which lack a valid physician’s signature on the order, claims which fail to meet specific medical necessity criteria, or even claims that were not submitted in a timely manner.

As an appellant, you must possess a thorough understanding regarding what has transpired from the reimbursement standpoint, end of story.  If you are an appellant, please read the basis for the claim denial being put forth by the third party payer. To take my Yogi quote further, it is impossible for you as an advocate to get where you want to go, that is, get paid, if you do not know why the claim has been denied. When you as an appellant receive a denial notice, whether it is an explanation of benefits or a remittance advice, review the basis for denial.  If it indicates that critical medical necessity evidence is missing, review your records to find it.

Arguments that the medical policy is foolish or that the payor doesn’t understand what the patient needs may make you feel better for having given the adjudicator a piece of your mind, but are ultimately ineffective. I once had an appellant argue to me that requiring a physician’s order was a foolish requirement for an orthotic device.  When I asked the gentleman making that arguments how a payor was to ascertain if an item was medically necessary, he indicated that they should just ask him, the vendor.  Needless to say that was not an effective argument.

If you have received a blanket denial, such as a lack of medical necessity, please reach out to the third party payor to ascertain what exactly is missing or unclear.  Once you have determined what the problem is, you are then in a position to solve it.

Know the coverage and payment guidelines.

My final recommendation is that you acquire an in-depth knowledge of the coverage and payment guidelines or medical policies which govern the items or services for which you are seeking payment.  As a hearing officer or ALJ, I would find myself frequently asking appellants or payor representatives to furnish the basis within the policies for the denial of items.  More often than not on both sides of a case, neither party could articulate why an item should or should not have been paid.

I suppose in those situations they turned to another quote from Yogi: “If you ask me a question I don’t know, I’m not going to answer it.” Today there is no reason for any party to be unaware or unknowledgeable regarding medical policies or coverage and payment guidelines. All commercial health insurers and government programs, such as Medicare and Medicaid, publish their policies online.  Knowledge of the rules is one of the cornerstones to being a strong advocate for your position. From the provider standpoint, it is one of the critical components needed in order to have an item covered by a payor.

My advice may seem rather basic, but years of experience have shown me that it is a failure to address the fundamentals which causes most claims to be denied. In summary: 1. Know your patient and the medical records surrounding a claim; 2. Know the facts surrounding why reimbursement has been denied; 3. Know the rules which govern payment criteria for your claim.

If you pay attention to the foregoing you will be a much stronger advocate for your position and will likewise achieve and maintain a higher success rate in your appeals. In medical benefit appeals, as in baseball, “It ain’t over until it’s over.”

About Keith J. Saunders, Esq.
Keith J. Saunders, Esq. is the Founder & CEO of FHAS, a leading provider of medical review analytics and support services to government and commercial sectors. Weaving together over 30 years of experience working on behalf of health plans, providers, and government agencies, Mr. Saunders furnishes his clients with valued-based solutions that minimize administrative waste, maximize return on investment, and yield holistic results for all stakeholders. A former General Counsel to Blue Cross Blue Shield Plans, Mr. Saunders was an Air Force Judge Advocate proudly serving in Operation Desert Shield/Desert Storm. Mr. Saunders attained his Juris Doctorate from Duquesne University and is a long-time member of the American Health Lawyers Association (AHLA).

About FHAS
FHAS, a URAC accredited IRO and ISO 9001 certified company, is one of the largest independent providers of “healthcare as a service” (HAAS) for government and commercial clients with a particular focus on adjudication services and medical claims’ review services. In 1996, FHAS began furnishing Medicare Fair Hearing Services to Durable Medical Equipment (DME) Administrative contractors located throughout the United States. Since that time, FHAS has expanded its scope of appeals services to include complex medical reviews for the following: Medicare Parts A, B, PDRC Appeals, and DME Appeals, internal and external health plan appeals, and the entire Pennsylvania Medicaid fair hearing process. FHAS utilizes a network of board certified physicians, legal professionals, and other healthcare professionals with diverse specialties, who have the expertise to render decisions for external review requests. In addition to professional services, FHAS provides enterprise-grade software solutions to healthcare and insurance industries. Their newest product Cogno-Solve is a comprehensive, RPA software platform that automates claims and appeals decision-making functions.

Mobile App Streamlines Physician Query Process

Posted on June 28, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Most physicians would tell you that they already spend too much time on documentation and coding. Adding insult to injury, after the coding job is done we often have to explain their decisions to medical coders, a process which can take as long as 20 minutes, according to vendor Artifact Health.

Artifact hopes to take the pain out of the burdensome physician query process. It offers a mobile app allowing doctors to answer coding queries which it says allow them to resolve problems within just three clicks. Physicians can also access the platform on the desktop.

Its approach bears some relationship to a new product from vendor Change Healthcare, which has just launched RCM technology which helps doctors address claims documentation requests. Change’s Assurance Assist Module, which is part of its Assurance Reimbursement Management suite, can anticipate the documentation needs of eight payers, the company said.

I am interested in both of these approaches because I know that physicians are already struggling to manage medical coding within their own practices. Hospital queries are a challenging part of that mix and feels like a major chore for providers. In fact, if Artifact’s research is correct and each traditional query takes 20 minutes to resolve, physicians could conceivably end up a little time to do anything else.

So far, Artifact seems to be rolling along impressively. The vendor says that more than 50 hospitals have come on board with its technology, including five institutions from Johns Hopkins Medicine. According to the vendor, these hospitals solve physician response rate of almost 100% and average response time within 48 hours for all periods.

Meanwhile, the hospitals found that the time it took for claims to get paid (days in Accounts Receivable) fell substantially, Artifact reports.

Lest it sound like I’m an Artifact investor, let me raise the questions I ask every time I get a look at a new health IT startup:

  • What does the software cost?
  • How long does it usually take to go live with the platform?
  • How much man- or woman power will it take to install and maintain the software?

At the moment I don’t know. As we all know, not only the initial investment, but also implementation and maintenance can catch hospitals by surprise.

The truth is, it’s likely any vendor addressing aspects of hospital RCM will be somewhat expensive and somewhat complex to install. I wish there were workable benchmarks giving hospital leaders a preliminary sense of their potential investment.

Regardless, this is a worthwhile area for RCM vendors to attack. Even if all this technology did was give doctors some relief, it might reach ROI over time. When you consider that tools like these can help coders get clean claims out of the door, it’s even better.

Despite EMR, Revenue Cycle Management Costs Were Still Substantial

Posted on April 26, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

While they may not say so out loud, most healthcare organizations bought EMRs largely because they believed they could use them to lower revenue cycle management expenses. If so, they may be somewhat disappointed. A new study has concluded that at least in one case, the presence of a certified EMR didn’t make much of a dent in these costs.

­To conduct the study, researchers conducted interviews with 27 health system administrators and 34 physicians at a large academic medical center. The interviews took place in 2016 and 2017. The research team used the feedback to create a process map charting the path of an insurance claim through the RCM process.

Using this data, the researchers calculated the cost of each major billing and insurance-related activity, as well as a total cost of processing a claim from end to end. The data included costs for five types of patient encounters, including primary care visits, discharge ED visits, general medicine inpatient stays, ambulatory surgical procedures and inpatient surgical procedures.

The team concluded that estimated processing times and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged ED visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure and 100 minutes and $215.10 for an inpatient surgical procedure.

To put these numbers in perspective, the research team noted that billing costs represented an estimated 14.5% of professional revenue for primary care visits, 25.2% for emergency department visits, 8% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures and 3.1% for inpatient surgical procedures.

There are more than a few unfortunate things to be seen in these numbers.

One is that primary care practices spent a very high percentage of revenue on RCM, which could be crushing given their typically low margins. Given that PCPs are already being squeezed by patients who can’t afford to meet their high deductibles, this is a recipe for financial disaster.

It’s also troubling to see that that the academic medical center in question was spending more than 25% of its ED revenue chasing insurance payments. I found myself wondering whether ED prices might drop to a reasonable level if it was easier for these departments to collect from insurers.

It’s scary to think that these numbers might’ve been higher before the academic medical center installed its EMR. As things stand, if the EMR is lowering RCM costs, it doesn’t seem to be having a major impact. But I’m just guessing here — what do you think?

Health IT Preserves Idaho Hospital’s Independence

Posted on February 1, 2017 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Most of the time, when I write about hospital IT adoption, I end up explaining why a well-capitalized organization is going into the red to implement its EMR. But I recently found a story in RevCycle Intelligence in which a struggling hospital actually seems to have benefitted financially from investing in IT infrastructure. According to the story, a 14-bed critical access hospital in Idaho recently managed to stave off a forced merger or even closure by rolling out an updated EMR and current revenue cycle management technology.

Only a few years ago, Arco, Idaho-based Lost Rivers Medical Center was facing serious financial hurdles, and its technology was very outdated. In particular, it was using an EMR from 1993, which was proving so inflexible that the claims stayed in accounts receivable for an average of 108 days. “We didn’t have wifi,” CEO Brad Huerta told the site. “We didn’t have fiber. We literally had copper wires for our phone system…we had an EMR in a technical sense, but nobody was using it. It was a proverbial paperweight.”

Not only was the cost of paying for upgrades daunting, the hospital’s location was as well. Arco is a “frontier” location, making it hard to recruit IT staffers to implement and maintain infrastructure, staff and servers, the story notes. Though “fiercely independent,” as Huerta put it, it was getting hard for Lost Rivers to succeed without merging with a larger organization.

That being said, Huerta and his team decided to stick it out. They feared diluting their impact, or losing the ability to offer services like trauma care and tele-pharmacy, if they were to merge with a bigger organization.

Instead of conceding defeat, Huerta decided to focus on improving the hospital’s revenue cycle performance, which would call for installing an up-to-date EMR and more advanced medical billing tools. After the hospital finished putting in fiber in its area, Lost Rivers invested in athenahealth’s cloud-based EMR and medical billing tools.

Once the hospital put its new systems in place, it was able to turn things around on the revenue cycle front. Total cash flow climbed rapidly, and days in accounts receivable fell from 108 to 52 days.

According to Huerta, part of the reason the hospital was able to make such significant improvements was that the new systems improved workflow. In the past, he told RevCycle Intelligence, providers and staff often failed to code services correctly or bill patients appropriately, which led to financial losses.

Now, doctors chart on laptops, tablets or even phones while at the patients’ bedside. Not only did this improve coding accuracy, it cut down on the amount of time doctors spend in administrative work, giving them time to generate revenue by seeing additional patients.

What’s more, the new system has given Lost Rivers access to some of the advantages of merging with other facilities without having to actually do so. According to the story, the system now connects the critical access hospital with larger health systems, as the athenahealth system captures rule changes made by the other organization and effectively shares the improvements with Lost Rivers. This means the coding proposed by the system gradually gets more accurate, without forcing Lost Rivers to spend big bucks on coding training, Huertas said.

While the story doesn’t say so specifically, I’m sure that Lost Rivers is spending a lot on its spiffy new EMR and billing tech, which must have been painful at least at first. But it’s always good to see the gamble pay off.

EMRs Aren’t Billing Software

Posted on January 6, 2014 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

The other day, I caught a piece in FierceEMR which brought up an important point.  In the article, the writer summarized comments by a medical practice manager and cardiologist who argues that the tight connection between billing and EMRs makes them less valuable for clinical use.

The article quotes Ira Nash, senior vice president and executive director at North Shore-LIJ Medical Group, who contends that “nearly all of the things that doctors dislike about [EMRs] are features designed to capture information needed for billing purposes.” In other words, he says, EMRs are focused on documenting with doctors did for or to the patient, not about how the patient was doing.

The bottom line, Nash suggests, is that fixing EMRs requires changing the way we pay for care:

Like so many other things that doctors hate about the current health care environment, the flaws of the current crop of commercially available EMRs are a consequence of how we pay for care. Since we are paid for “doing stuff,” we are constantly being challenged to prove that the stuff we are doing is justified, and that we actually did it. We are getting killed by the focus on process. We ought to be focusing on outcomes.

While it’s hard to argue that Dr. Nash is wrong — that a focus on billing for “doing stuff” turns EMRs into billing software — my question is, what is the alternative?  Or rather, what is the best alternative (as EMRs will inevitably have some connection to the billing process even if my colleague John Lynn asked us in 2010 to imagine an EMR world without billing)?

After all, billing does need to be done correctly; if that doesn’t happen, the healthcare organization loses money, or may even face a CMS or private health plan audit, and nobody wants that for their practice. So where do we go from here?

CMS Now Auditing Meaningful Use Documentation

Posted on August 15, 2012 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

It’s been a while since our beloved Recovery Audit Contractors (RAC) were on the front page of the trades every day, but they’re far from gone.  In fact, CMS has started to get aggressive in a few new ways, according to the Fox Group:

  • Meaningful Use Attestation Audits:  So you’ve collected EMR data, you’ve attested, and you’re waiting for your check. All is well, right?  Not necessarily. CMS has begun requesting documentation from providers that supports  the attestation, largely data from your EMR but also possibly info from internal audits you’ve conducted to see that you’re meeting objectives.  This is big stuff; if you fail your audit by CMS, there goes your money. And in the future, if you fail multiple audits, you could be seen as submitting false claims. Mega-ouch.
  •  MACs Look At Documentation:  Medicare Administrative Contractors (MACs) have been auditing medical records for years to make sure documentation supports the services billed. Now, they’re going to start looking at “auto-generated data” produced by EMR medical record documentation systems.  If the auto-documentation looks “cookie-cutter” and possibly out of line for some specific patients, providers could be in trouble.

And if you somehow get entangled with a RAC investigation, don’t count on carefully-spelled-out EMR documentation to save you. According to a recent study by the American Hospital Association, 77 percent of claims denied by RACs were restored upon appeal, suggesting that most of the time, claims targeted by the RACs weren’t bad to begin with. In other words, I think it’s fair to say that they’re out for blood, so prepare yourself.

An internal audit of your documentation can work wonders, Fox Group suggests. And keep an eye out for copy-and-paste documentation across bunches of patients; it’s gone from questionable to perilous.