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Medicare denials are a way to start communication, not a sign of failure
Hospice medical directors offer tips
Hospices often make two mistakes with regard to Medicare denials: First, they try too hard to avoid receiving denials, and, secondly, they do not appeal out of fear of reprisal.
These are precisely the wrong strategies to take, experts say.
"The biggest mistake a hospice program can make is to try to never have a denial because then they'll miss caring for people who need hospice care," says Laurel H. Herbst, MD, vice president of medical affairs and chief medical officer at San Diego Hospice & Palliative Care in San Diego, CA.
"You need to take the attitude of like it's a surgeon's appendectomy rates, where you need about 5 percent of the appendix coming out healthy to know that you've done the right number of necessary appendectomies," Herbst says.
"If you have no Medicare denials, then you're turning away people who need your care," she adds.
It's a common fear among hospice medical directors and others that if they appeal a Medicare decision then they'll make the reviewers angry and the Medicare intermediary then will spend more time looking at their hospice, says Charles F. von Gunten, MD, PhD, FAHHPM, provost and vice president, Center for Palliative Studies at San Diego Hospice & Palliative Care. Von Gunten also is the editor-in-chief of the Journal of Palliative Medicine. von Gunten and Herbst spoke about handling Medicare denials at the American Academy of Hospice & Palliative Medicine (AAHPM) conference, held Feb. 14-17, 2007, in Salt Lake City, UT.
"So, they believe it's better not to appeal because an appeal will stimulate the intermediary's interest in you," von Gunten adds.
"That's a common fear, and it's not true," he says. "When you appropriately appeal cases, in our actual experience, the overall number of reviews goes down."
This is because the Medicare intermediary quickly learns that a particular hospice cannot be intimidated and it has high standards of medical care that the hospice medical director is willing to defend, von Gunten says.
Herbst and von Gunten offer these tips on how to handle Medicare denials:
1. Review the denial for misunderstandings or documentation issues that can easily be explained in an appeal.
"Many hospice directors, when they receive a denial, will react emotionally, thinking they did something wrong, and they'll try to prevent it from ever happening again," von Gunten says.
"Instead of reacting like that, you need to say, 'We did the right thing, and we'll appeal this,'" Gunten says. "If hospice medical directors take on that role, then patients are going to get the right care, and hospices will improve."
There are many good reasons to appeal the denials because the Medicare reviewers are not necessarily expert reviewers, and they have their own biases, Herbst says.
For example, Herbst once received a denial on a patient who had heart failure.
The denial said that the patient clearly was not terminal because she was gaining weight instead of losing weight, Herbst recalls.
"In heart failure, gaining weight means your feet are swelling, and that's not a good sign," she explains. "In a heart failure patient, the feet are swelling up because the person's heart is worse than it ever was."
Herbst used the patient's medical data and interpreted it medically to provide the Medicare reviewer with the proper context, which was missing in the denial.
"Medicare reviewers are looking only at isolated facts, and they're not sophisticated in interpreting the data," von Gunten says.
These kinds of medical misunderstandings are common, Herbst says.
She's also had patients with pulmonary fibrosis who were treated by the Medicare reviewer the same as patients with chronic obstructive pulmonary disease, although the symptoms are different and, therefore, the hospice care is different, Herbst says.
"I had a patient with a critical aorta stenosis, which is a condition where the patient is likely to die suddenly because of a lack of blood flow to the brain," Herbst says. "These patients are classed by Medicare with congestive heart failure (CHF) patients, although they don't have CHF."
Since they're classified the same as CHF, Medicare reviewers will deny hospice care because they lack CHF signs and symptoms, oblivious to the fact that these patients will die much faster than CHF patients, Herbst adds.
"Hospice medical directors need to be very good physicians who have a broad understanding of medicine," von Gunten says. "They need to help Medicare reviewers understand the nuances of medicine."
2. Respond immediately.
The key is to send the Medicare intermediary a clear, informative letter that explains why the patient's care was necessary and met all the criteria, Herbst says.
These letters take about 20 minutes on average, depending on the medical chart, Herbst notes.
Herbst repeats in her appeal letter the exact language used in the denial, putting it in quotation marks.
The letter then summarizes the physical information briefly and draws a clear picture of a very sick patient, listing the patient's condition, as well as specific elements that indicate the patient is terminally ill. The letter also will refute any inaccurate data stated in the Medicare denial, and it will request Medicare to reverse its denial, Herbst explains.
"If you don't ask for the reversal of denial, then they will not do it," she adds.
One recent trend Herbst has noticed involves letters from Medicare intermediaries in which the intermediary has suspended the decision to approve the claim until more information is obtained from the hospice.
If this is a tactic to delay payment, it will work unless the hospice director immediately answers it, Herbst says.
"They'll give you 60 days to get the information back, but if you wait, that delays your hospice from getting paid," she says. "I usually have those back in the return mail, explaining exactly why the patient got the care he or she got."
Most of the denials Herbst sees these days involve denials of levels of care, rather than the denials for length-of-stay and prognosis reasons, she notes.
"These are much easier to handle because all you need to indicate is the reason for the general inpatient care (GIP) status and why the patient was admitted," Herbst says.
3. Use the appeal process as an opportunity to improve everyone's education about hospice documentation and care.
"The other role for the physician here is to read your own staff medical records critically, using the information to teach better documentation skills to your own staff," Herbst says.
"I have had denials happen where the nurse may have documented that the patient was not having pain, when the fact was the patient was on 200 mg of morphine per hour, which controlled the pain," Herbst says. "But if the chart says the person doesn't have pain, then the reviewer doesn't go to the next step to see if the patient is on medicine, and will think the patient doesn't need any hospice care."
The correct way to document this is to say that the pain is well-controlled by the name of the patient's medicine, Herbst explains.
"This is the same with documenting other symptoms," von Gunten says. "You should write, 'The nausea is controlled by X drug; the shortness of breath is controlled by X drug.'"
These are the sort of chart nuances that can cause a claim to be denied, Herbst says.
"I've managed to win all of these types of appeals by pointing out that the patient is on 200 mg an hour of morphine," Herbst says. "But if the nurse were to chart it that way to begin with then we wouldn't even get the denial."
Hospice medical directors should see it as part of their job to handle Medicare denials, she adds.
"Medicare has an obligation to pay for needed care and nothing more than that," von Gunten says. "On the hospice side, you need to defend what you do and explain it, because if you don't, then patient care will be affected."
Handling Medicare denials and appeals is another way of educating the hospice community, Herbst says.
"I have had fewer denials now than I used to have, and I think it's because I've trained others," she adds.
Herbst says that handling Medicare denial appeals has helped to improve her own thinking, as well as her teaching skills. She educates her staff and physician trainees about Medicare documentation and reviews.
"When I first noticed a trend like the pain medication documentation problem, I started by speaking with our team of directors and sent them emails as a heads up," Herbst says.
The directors discussed her emails in team meetings, and Herbst also spoke with other hospice physicians about the problems, and they, too, spread the word.
Since hospices in different parts of the country have different Medicare intermediaries, their experiences might differ when appealing denials, Herbst notes.
"Our intermediaries are quite reasonable and easy for me to deal with," she says. "I spend a lot of time working with them to understand their process and to help them understand ours."
It's a good idea for all hospice medical directors to get to know their intermediary representatives as people rather than as letters on a page, Herbst suggests.
"I've gone to meetings with them and also had phone conversations," she says. "I often call them up to ask their opinion."
For instance, Herbst was proactive when the hospice was considering changing the way it used nurse practitioners (NPs). She called the Medicare intermediary medical director and discussed how the hospice wanted to use NPs, asking the medical director for advice on how this could best work and how the hospice would bill for the care.
"I think it would be helpful if people had more proactive conversations with intermediaries because it helps to make sure we all understand something the same way," Herbst says.
"Medicare intermediaries loom large in your imagination as fearsome when they're just trying to do their job just like you're trying to do yours," von Gunten says.
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