September 2016

At a Disadvantage?
By Lisa A. Eramo
For The Record
Vol. 28 No. 9 P. 10

Many providers feel under the thumb of Medicare Advantage plans.

If you're on a budget—and who isn't these days?—you probably tighten your purse strings once in a while to ensure your bills are paid on time. Now imagine that you're the Centers for Medicare & Medicaid Services (CMS). According to the latest data from paymentaccuracy.gov, the agency has made $14.1 billion in improper payments to its Medicare Advantage (Part C) supplemental plans, representing a 9.5% improper payment rate.

During a time when every penny counts, it's not surprising that CMS has begun to take a closer look at its expenditures in this growing market.

Through its risk adjustment data validation audits of Medicare Advantage plans, CMS examines whether its risk-adjusted payments to these plans are appropriate based on actual provider documentation. Medicare Advantage plans are paid according to CMS' hierarchical condition category (HCC) model that takes each beneficiary's specific health risks and certain demographic characteristics into consideration. In essence, CMS pays Medicare Advantage plans a monthly capitated rate to cover expenses for patients with greater risk, meaning those who have multiple HCCs.

However, experts say that CMS' scrutiny of Part C payments has led some Medicare Advantage plans to become particularly aggressive with providers in terms of denying payment.

What ends up happening, explains Jacqueline E. Poliseno, RN, BSN, CPHM, manager of consulting and appeals at Craneware, is that Medicare renders prospective risk-adjusted payments based on the previous year's data. Therefore, it's financially advantageous for Medicare Advantage plans to pocket this money on the front end and deny as much as possible to providers on the back end.

"It's very frustrating for providers," says Wendy Gagnon-Dutro, CPC, CAC, director of coding solutions at Aviacode. As with all insurers and auditors, Medicare Advantage plans seem to target providers whose documentation doesn't reflect ongoing treatment for HCC conditions. Payers want to see that providers are actually treating all of the HCC diagnoses that have the potential to shift the diagnosis-related group (DRG) and not just identifying them within the record and moving on, Gagnon-Dutro says.

If the supporting documentation for any secondary diagnoses is absent from the record, the Medicare Advantage plan will surely downgrade the DRG. Recovery auditors have been doing this for a while, Poliseno says, adding that all payers eventually "take the lead from what's happening in the Medicare world."

Medicare Advantage plans also typically take a proactive approach to payment, meaning they withhold funds out of the gate rather than pay claims, perform retrospective audits/denials, and recoup money, Poliseno says. "This means providers are in a position of having to chase after their money if they think they're so deserving," she says.

Digging Deep
In addition to high volumes of denials, experts say there are other ways in which Medicare Advantage plans have posed barriers to reimbursement, some of which are more justified than others. Among the most common complaints are the following:

• No predictability or consistency: "It's almost like the MACs [Medicare administrative contractors] in traditional Medicare," says Holly Louie, RN, CHBME, PCS, compliance officer at Practice Management, Inc, and president of the Healthcare Billing and Management Association. "Some of the Part Cs that we work with are wonderful. We very rarely have an issue. There are others that are extremely difficult."

Devendra Saharia, CEO at AGS Health, agrees. "When we talk about Medicare Advantage plans, they make their own rules. … I think this is the biggest risk," he says.

• Difficulty obtaining authorization for hospital stays: "Negotiation on the front end has become very labor intensive," Poliseno says, noting that this is especially true for urgent admissions, where it can take the Medicare Advantage plans as long as several days to respond with authorization. "This is really frustrating because by the time they come back to us, the patient may have already been discharged."

At this point, providers have little recourse. A physician-to-physician review may be necessary; however, even this can be difficult, as each plan has its own nuances and challenges, says Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, director of content at Find-a-Code. Even in cases where physician-to-physician communication is required, "the information doesn't always make it into the chart in the same way in which the provider describes it," she says.

If that doesn't work, the only option is to submit the claim (assuming documentation supports an inpatient admission), let it be denied due to a lack of prior authorization, and go through the appeal process, Poliseno says.

Unfortunately, many Medicare Advantage payers are moving toward a nonretrospective authorization model, Saharia says, meaning providers have few appeal options. In addition, the likelihood of a successful appeal is slim.

• Added complexity related to the two-midnight rule: Poliseno says many Medicare Advantage plans require providers to meet CMS' two-midnight rule—providers must document a reasonable expectation that the patient will stay in the hospital for at least two midnights—as well as utilization review (UR) criteria. Medicare fee-for-service also requires compliance with the two-midnight rule, but not necessarily with all of the UR criteria, she adds.

A Medicare Advantage plan member may stay two midnights but not meet UR criteria—and providers still receive a denial, Poliseno says. The good news is that in many circumstances, these denials can be overturned when there is a documented clinical reason for the inpatient admission, she says. "But that begs the question: If you can win them on appeal, why aren't they being paid up front?" Poliseno says.

• Lack of communication: "Getting anyone in provider services to talk with you is virtually impossible," Louie says. "If you do get someone, they're usually not knowledgeable on the issues." She says it's particularly difficult to obtain answers to technical questions that require explanation beyond what the Medicare Advantage plan has provided in its brochures and bulletins (eg, how the payer adjudicates a complex clinical scenario).

Some Medicare Advantage plans also don't communicate regarding overturned denials, Poliseno says. "We're continually chasing after them to get some sort of recognition that the appeal has been overturned and that they do owe us the money," she says.

• Nonpayment for services covered by Medicare: "On the remit, it will actually say 'not covered,' and many times that is an absolute false statement," Louie says. "It is clearly covered under the national CMS policy as well as the local MAC policy. Even when we send them the actual policies highlighted—and the Medicare manual highlighted—it's just completely ignored."

For example, take CT lung screenings. Effective February 5, 2015, Medicare began to cover screening for lung cancer with low-dose CT. However, the corresponding national coverage determination (NCD) didn't include ICD-10 updates and corrections until July. Louie says some of the Part C plans are recouping money for tests performed prior to July, arguing that it was a noncovered service until the NCD was officially updated.

"These plans have indicated that they're not going to go back and reprocess those claims for payment," she says. "We have asked CMS to intervene on this issue, but I don't know if we'll have any success."

In general, Louie says many Medicare Advantage plans bet on the fact that providers simply won't appeal these and other denied claims. "In many cases, these Part C plans deny claims knowing that providers aren't going to fight it," she says. "They're not going to appeal it. They're just going to accept an improper write-off because they just don't have the staff to fight this kind of battle."

Compliance Tips
Experts offer the following tips to mitigate risk for Medicare Advantage denials:

Perform HCC audits. In doing so, consider the following questions:

• Has the physician clearly identified all HCC conditions and labeled them as active?

• Does the documentation indicate that the active HCC conditions are being monitored, evaluated, assessed/addressed, or treated? Note that the physician must describe this information fully. Encourage physicians not to over-rely on EMR templates, Gagnon-Dutro says. Payers and auditors want to see narrative information that describes ongoing treatment, not just the selection of a diagnosis from a drop-down menu, she says.

• Does the documentation reflect all the specificity necessary for ICD-10? "The specificity can be really detailed," Wilcox says. "When you're documenting, if you're not hitting all of the key information, it makes a difference." Consider automated tools to help physicians identify HCCs and to prompt them to provide the necessary documentation, she adds.

• Do physicians indicate the status of any cancer as well as its treatment?

• Do physicians indicate whether certain diagnoses, such as hepatitis and renal insufficiency, are chronic?

• Do physicians document a link between complications and their manifestations?

Review contracts before signing them. What are your appeal rights? Redetermination rights? Is there an "out clause" if the contract becomes detrimental to your bottom line?

"There are a lot of provider offices that basically just sign the contract without really reviewing it," Wilcox says. "I've seen them sign away on a contract that doesn't even include the codes that they provide on a regular basis."

When necessary, involve CMS. If the plan continually circumvents its own obligations per the contract, consider reaching out directly to CMS, Wilcox says. "These are private insurance companies that are running the Part C programs. These companies are bound and audited by CMS just like medical providers and facilities. They are watched very carefully," she notes.

Identify dedicated provider representatives. "The insurance companies with which we've had the best success are the ones with which we've been able to build a good working relationship," Louie says.

Analyze your data. "You have to understand what's being denied and why—and invest your time where it matters," Louie says. "If it's a pattern, then there needs to be a way to quantify and demonstrate that so you have some kind of a leg to stand on."

Saharia agrees. "Analytics are becoming more and more prominent in preventing and appealing denials," he says. "The analytics will be able to provide insights into trending and ultimately lead to prevention. The analytics will also determine what specific area is responsible for the denial, such as preregistration, registration, coding, clinical documentation, or eligibility checking. Denials can be mapped into these larger categories so that focus can be placed where it is needed most."

If most denials are being overturned on appeal, Poliseno recommends letting the payer know. "Take that information back to the payer and work with them around expectations. Insist on contract language that supports timely reimbursement for medically appropriate care," she says.

Establish an up-front eligibility process. Wilcox says patients frequently switch Medicare Advantage plans or forget that they even have these plans. It's a provider's responsibility to verify this information on the front end to mitigate the risk of denial, she says.

Pay attention to throughput (ie, delays in the care process). Consider a patient who is admitted on Monday and requires a catheterization that isn't performed until Wednesday. Poliseno says some Medicare Advantage plans are denying the length of stay, stating that it could have been lessened had the procedure been performed that same day or the following day.

Providers need to identify—and mitigate—care gaps, when possible, though she admits that may be challenging for small, rural providers. "Sometimes this may not be realistic. A community hospital may not staff its cardiac cath lab on the weekends. It's an enormous expense to have that level of staff available seven days a week," she says. "If the discharge cannot happen until the catheterization has been accomplished, it may make more sense financially for them to keep the patient and risk the denial."

In these cases, Poliseno recommends providers determine whether the patient is stable. Is it possible he or she could go home and come back when the lab is open?

Get patients involved. "In some cases, it's so egregious that we've written letters to the beneficiaries and given them copies of the authoritative documents," Louie says. "We tell them that their Part C plan is denying a legitimately covered service." Once patients are involved, she says, payers are more likely to respond positively.

Interestingly, CMS uses information from member satisfaction surveys to rate the performance of Medicare health and prescription drug plans, including Medicare Advantage plans, using a five-star system. The overall score for each health plan is driven by a variety of factors, including how often members file a complaint or appeal as well as how well the plan handles calls from its members. Beneficiaries can use this information to compare plans based on quality and performance.

Face difficult decisions. Louie says some providers ultimately decide not to participate with certain plans, including Medicare and Medicare Advantage. "They're becoming more savvy in terms of the plans that are just not worth the trouble," she says.

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.