Author Topic: Independent Review- Assistance needed (original issue in the 'No Preauth' thread  (Read 792 times)

PippiT

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To make a long story short, my complaint to the State Insurance Commission was passed to the State Attorney General's office. I have been working with an investigator and the investigation is winding down and she says this is no longer a billing issue. The patients insurance is not going to pay just because they miscommunicated with us, they are not going to pay because they consider it investigational.

She said the first next step is it will be going for an Independent Review with the patients employer. She said with this the focus is going to shift to ALL ABOUT MEDICAL NECESSITY.

1. She needs for us to be looking at what criteria the industry is doing for this type of procedure
2. We need information that we can present to the IRO, because they can overturn and make his insurance pay but the more documentation we have for this, the better.
3. She said this is where they step in because they (AG's office) to advocate for the patient because in the end they don't want us billing the patient.

I contacted our rep at Amnioband and he sent me this:

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35041&ver=50&CntrctrSelected=331*1&Cntrctr=331&DocType=Active&bc=AgACAAIAIAAAAA%3d%3d&

I will post what specifically from the link below. This is my first IRO and I would appreciate any pointers of where to look for information that will help us get our claims paid.  That wasn't very short! Thank you!!




PippiT

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Specifically, this is from the link:
Covered Indications:

Chronic Wounds are defined as wounds that do not respond to standard wound treatment for at least a 30 day period during organized comprehensive conservative therapy.

For all wounds, documentation (as outlined in the documentation requirements of the policy) and a comprehensive treatment plan, before initiation of a specialized wound therapy product is required.

For purposes of this LCD a Failed Response is defined as an ulcer or skin deficit that has failed to respond to documented appropriate wound-care measures, has increased in size or depth, or has not changed in baseline size or depth and has no indication that improvement is likely (such as granulation, epithelialization or progress towards closing).

Medicare covers application of skin substitutes to Ulcers or Wounds with Failed Response that are:
•   Partial- or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean granular base;
•   Skin deficit at least 1.0 cm² in size;
•   Clean and free of necrotic debris or exudate;
•   Have adequate circulation/oxygenation to support tissue growth/wound healing as evidenced by physical examination (e.g., Ankle-Brachial Index (ABI) of no less than 0.60, toe pressure > 30mm Hg);
•   For diabetic foot ulcers, the patient’s medical record reflects a diagnosis of Type 1 or Type 2 Diabetes and also reflects medical management for this condition.

Wound healing is impaired by the systemic use of tobacco. Therefore, ideally patients who have smoked will have ceased smoking or have refrained from systemic tobacco intake for at least 4 weeks during conservative wound care and prior to planned bioengineered skin replacement therapy.

Documentation (in the pre-service record) specifically addressing circumstances as to why the wound has failed to respond to standard wound care treatment of greater than 4 weeks and must reference specific interventions that have failed. Such record should include updated medication history, review of pertinent medical problems that may have occurred since the previous wound evaluation, and explanation of the planned skin replacement surgery with choice of skin substitute graft product. The procedure risks and complications should also be reviewed and documented. Documentation of smoking cessation counseling and cessation measures prescribed, if applicable, must also be documented in the patient's record.

Application of a skin substitute graft for lower extremity chronic wound (DFU and VLU) will be covered when the following conditions are met for the individual patient:
•   Presence of neuropathic diabetic foot ulcer(s) having failed to respond to documented conservative wound-care measures of greater than four weeks, during which the patient is compliant with recommendations, and without evidence of underlying osteomyelitis or nidus of infection.
•   Presence of a venous stasis ulcer for at least 3 months but unresponsive to appropriate wound care for at least 30 days with documented compliance.
•   Presence of a full thickness skin loss ulcer that is the result of abscess, injury or trauma that has failed to respond to appropriate control of infection, foreign body, tumor resection, or other disease process for a period of 4 weeks or longer.
In all wound management the ulcer must be free of infection and underlying osteomyelitis with documentation of the conditions that have been treated and resolved prior to the institution of skin substitute therapy. For purposes of this LCD, appropriate therapy includes, but is not limited to:

o   Control of edema, venous hypertension or lymphedema
o   Control of any nidus of infection or colonization with bacterial or fungal elements
o   Elimination of underlying cellulitis, osteomyelitis, foreign body, or malignant process
o   Appropriate debridement of necrotic tissue or foreign body (exposed bone or tendon)
o   For diabetic foot ulcers, appropriate non-weight bearing or off-loading pressure
o   For venous stasis ulcers, compression therapy provided with documented diligent use of multilayer dressings, compression stockings of > 20mmHg pressure, or pneumatic compression
o   Provision of wound environment to promote healing (protection from trauma and contaminants, elimination of inciting or aggravating processes)
Limitations:

The following are considered not reasonable and necessary and therefore will be denied:

Due to the propensity for misuse of skin substitute and biological dressing products, reimbursement may be made only when the medical record clearly documents that these products have been used in a comprehensive, organized wound management program. All listed products, unless they are specifically FDA-labeled or cleared for use in the types of wounds being treated, will be considered to be biologic dressings and part of the relevant Evaluation and Management (E/M) service provided and not separately reimbursed.
•   Partial thickness loss with the retention of epithelial appendages is not a candidate for grafting or replacement, as epithelium will repopulate the deficit from the appendages, negating the benefit of overgrafting
•   Skin substitute grafts will be allowed for the episode of wound care in compliance with FDA guidelines for the specific product (see utilization guidelines) not to exceed 10 applications or treatments. In situations where more than one specific product is used, it is expected that the number of applications or treatments will still not exceed 10
•   Simultaneous use of more than one product for the episode of wound is not covered. Product change within the episode of wound is allowed, not to exceed the 10 application limit per wound per 12 week period of care.
•   Treatment of any chronic skin wound will typically last no more than twelve (12) weeks.
•   Repeat or alternative applications of skin substitute grafts are not considered medically reasonable and necessary when a previous full course of applications was unsuccessful. Unsuccessful treatment is defined as increase in size or depth of an ulcer or no change in baseline size or depth and no sign of improvement or indication that improvement is likely (such as granulation, epithelialization or progress towards closing) for a period of 4 weeks past start of therapy.
•   Retreatment of healed ulcers, those showing greater than 75% size reduction and smaller than .5 sq.cm, is not considered medically reasonable and necessary.
•   Skin substitute grafts are contraindicated and are not considered reasonable and necessary in patients with inadequate control of underlying conditions or exacerbating factors (e.g., uncontrolled diabetes, active infection, and active Charcot arthropathy of the ulcer extremity, vasculitis or continued tobacco smoking without physician attempt to effect smoking cessation).
•   Skin substitute grafts are contraindicated in patients with known hypersensitivity to any component of the specific skin substitute graft (e.g., allergy to avian, bovine, porcine, equine products).
•   Repeat use of surgical preparation services (CPT codes 15002, 15003, 15004, and 15005) in conjunction with skin substitute application codes will be considered not reasonable and necessary. It is expected that each wound will require the use of appropriate wound preparation code at least once at initiation of care prior to placement of the skin substitute graft.
•   Re-treatment within one (1) year of any given course of skin substitute treatment for a venous stasis ulcer or (diabetic) neuropathic foot ulcer is considered treatment failure and does not meet reasonable and necessary criteria for re-treatment of that ulcer with a skin substitute procedure.
CMS has guidance regarding other specialized wound treatment technology and specifically addresses platelet rich plasma systems (e.g., Autologet, Magellan); negative pressure wound therapy devices and electro-magnetic/ultrasound/mist therapies. They are not addressed in this LCD as their role in the treatment of the two major types of lower extremity wounds discussed here is limited. Utilization remains at the provider’s discretion and must be reasonable and necessary. Note that combination therapy with any bioengineered skin substitute (CTP) will be considered not reasonable and necessary.

Michele

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To be honest this is a very specific issue and we only have pieces.  I will try to provide some tips but it's difficult without knowing more which would be impossible for you to share on a post:

1.  Make sure you have all information available and in an organized format.  Include the claim, any eobs or correspondences from the insurance including denials or requests for information.
2.  If information was requested and sent, have copies of exactly what was sent in.
3.  Have any documentation supporting the service performed, including anything from Amnioband.
4.  Have the provider write a letter/statement explaining what was done, why it was done, and how effective it was.  The statement should explain why this method was used as opposed to other methods that may not be considered experimental. 

That's really all you can do.  Have as much supporting documentation available as possible and then let them do their review.
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PMRNC

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One thing I didn't see in the original post was the TYPE of insurance plan this is. In the second post I did see mention of Medicare and LCD but I don't want to assume this is Medicare because the first post says review/appeal was done with the state dept of insurance.

With those things in mind, there is a HUGE question that should be answered first as it will determine WHERE your appeal goes and HOW to do it.

Is the plan an ERISA plan? IF it is.. the state dept of insurance and even your state AG office is completely USELESS. ERISA is on the federal level.  If you are unsure if it's ERISA you want to answer the following questions:

1) is this a "GROUP" health plan?
2) If it is a group health plan, is it a church/state/govt entity? If one of those, it's NOT ERISA
3) If it is a group health plan and it's not a church/govt/state plan it IS ERISA.

Here is a HINT.. MORE than 85% of claims you submit on behalf of any provider/entity ARE ERISA and most medical billers don't understand ERISA or how to go about filing an appeal.
Linda Walker
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PippiT

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It is not ERISA, it is a state group plan, patient is a police officer. Patient has a chronic non-healing diabetic ulcer hole in his foot.

The carrier is Cigna.

I am frustrated because the provider wants to harp on the fact that 4 CSRs told us that the codes were covered and is really not helping me gather information to aid his case for medical necessity.

What other information do you need? I could use some guidance. Thanks.
« Last Edit: July 18, 2017, 11:15:39 AM by PippiT »

PMRNC

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Ok, since not ERISA, you pretty much have exhausted with the State Dept / AG. The Customer service rep's are covered by their disclaimer that " benefits quoted are not a guarantee...etc., etc."  The services are  "NON" Covered as you found out with even the state dept of insurance. At this point, what I would do is bill the patient as there is nothing else you CAN do. In meantime you can let the IRO play out, I would say to cover the practice's butt and make sure patient understands you are doing this FOR them but bottom line they are responsible for out-of-pocket.
Linda Walker
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PippiT

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Ok, since not ERISA, you pretty much have exhausted with the State Dept / AG. The Customer service rep's are covered by their disclaimer that " benefits quoted are not a guarantee...etc., etc."  The services are  "NON" Covered as you found out with even the state dept of insurance. At this point, what I would do is bill the patient as there is nothing else you CAN do. In meantime you can let the IRO play out, I would say to cover the practice's butt and make sure patient understands you are doing this FOR them but bottom line they are responsible for out-of-pocket.

Yes, that is the plan but I have to come up with studies and documentation for Amnioband and anything I can find to submit to help our case for medical necessity. I've googled a few things that can't hurt but without the providers cooperation I'm afraid I will not have the proper documentation. In the end I've done my part so it's all I can do. 

I'm not sure what the doctor is planning to do  regarding billing the patient. I relayed the message from the AG that he needs to be thinking about that possibility. I guess he's waiting for the IRO to play out before deciding next steps.

Thank you for your response, it confirmed what I already thought! 

PMRNC

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Quote
I'm not sure what the doctor is planning to do  regarding billing the patient. I relayed the message from the AG that he needs to be thinking about that possibility. I guess he's waiting for the IRO to play out before deciding next steps.

Depending on whether the services were rendered or not it might be a good idea to at least discuss the "Plan B" options. If this were my client or even employer I would definitely discuss the plan B immediately. I would also take into consideration what the patient was told prior to services if they were rendered. This isn't something I would only "wait and see" about if the costs are high. If services were already rendered with the patient believing they were covered, certainly there can be more discussion with the patient on payment.
Linda Walker
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www.billerswebsite.com

PippiT

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I wanted to give an update, the IRO was successful and they overturned all the claims. THANK YOU ALL for your responses, it helped me tremendously as this was my first claim to take all the way. I have a question, hoping someone can help me.

The provider disputes the Out of Network allowed amounts. I went through the proper channels and disputed the payments as they were repriced by Viant. Viant is saying they are not willing to negotiate. My question is can I send these claims to a CollectRX type company? Ssince these claims were paid by overturning I don't know if that would make them ineligible or not?


Michele

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First of all, congratulations on getting them overturned!  Good work!

So basically they did overturn and pay but the provider does not want to accept the amounts, correct?  If the provider is out of network they can bill the patient for the amount above what the insurance carrier allowed.  I'm not familiar with CollectRX in particular but it appears they are a revenue cycle management company.  Since you already did the work of getting the claims overturned it seems like you might not need a full service like them.  Have you tried billing the patient yet?  I would try billing first on my own.  If the patient indicates they aren't going to pay, or doesn't respond, then I would do something more like collections.  We use a soft collection agency that has great results.



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PippiT

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First of all, congratulations on getting them overturned!  Good work!

So basically they did overturn and pay but the provider does not want to accept the amounts, correct?  If the provider is out of network they can bill the patient for the amount above what the insurance carrier allowed.  I'm not familiar with CollectRX in particular but it appears they are a revenue cycle management company.  Since you already did the work of getting the claims overturned it seems like you might not need a full service like them.  Have you tried billing the patient yet?  I would try billing first on my own.  If the patient indicates they aren't going to pay, or doesn't respond, then I would do something more like collections.  We use a soft collection agency that has great results.

Thank you! It was hard and I learned a lot. Even the rep at the AG's office was surprised at the outcome.

Yes, that is correct. We are billing the patient for the ded and coin. we can balance bill but the provider wants a larger allowed amount. In the past, Viant has negotiated with us, this time they are basically saying if it's covered under ERISA, try your luck there or bill the patient.  We have used Collect RX to get larger payments for past out of network claims. The provider will  not use a collection agency, I am the collector and if it gets to a point, we take delinquents to small claims. I would much prefer a collections agency!!

Thank you for your response. I wanted to see if there were any options other than billing the patient before presenting the bad news to the provider.

Michele

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I get it.   Just curious, why will the provider not use a collection agency?  I'm assuming it's for the same reason many don't and it's that they don't seem to be effective.  We experienced the same thing for many years.  We used many different collections agencies but not one had any kind of results.  It was a total waste.  Honestly I wasn't sure how they stayed in business.  They only got paid on what they collected and for us it was always nothing!

But we have found an agency that has amazing response rates.  They are soft collections and are kind of in between regular billing and collections.  They have a couple of different options including Rapid Recovery and Accelerator.  I believe their collection rate under Accelerator is in the 90% range!  THey are great to work with.  Full disclosure:  I get nothing for referring people to them.  I just truly love the results we get and our rep (who can handle any account in the US) is wonderful to work with.  The name of the company is Transworld and our rep is Richard Neary.  I can get anyone his contact information if desired.

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PippiT

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I get it.   Just curious, why will the provider not use a collection agency?  I'm assuming it's for the same reason many don't and it's that they don't seem to be effective.  We experienced the same thing for many years.  We used many different collections agencies but not one had any kind of results.  It was a total waste.  Honestly I wasn't sure how they stayed in business.  They only got paid on what they collected and for us it was always nothing!

But we have found an agency that has amazing response rates.  They are soft collections and are kind of in between regular billing and collections.  They have a couple of different options including Rapid Recovery and Accelerator.  I believe their collection rate under Accelerator is in the 90% range!  THey are great to work with.  Full disclosure:  I get nothing for referring people to them.  I just truly love the results we get and our rep (who can handle any account in the US) is wonderful to work with.  The name of the company is Transworld and our rep is Richard Neary.  I can get anyone his contact information if desired.

Viant has decided to negotiate with us on all but 2 claims, so I am waiting to see if we come to an agreement and if so I will try to have them reopen the two claims. They have assigned them to 4 different reps, so this has been fun.

I'm not sure the entire reason, as they stopped using collections long before I came along, but they never followed through with small claims until I came along. I'm assuming they want the entire bill paid and not have to share or pay someone else. We have taken the first round of delinquents to small claims and it has been effective to get them to pay before court and the ones who came to court we entered into a court ordered agreement for monthly payments that includes interest and rebilling fees. I guess this is an experiment to see how this goes since they have never followed through on their threats until now!

 I am always open to resources to make my job easier. I will reach out to Richard and see what I can find out thanks! Just out of curiosity, how long do you give patients to pay before turning over to collections?

Michele

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Our standard rule is send three notices.  We send the first bill once we receive payment from the insurance carrier.  Then we send a 2nd notice 30 days later.  If no response to the 2nd notice we send out a final notice 30 days after the 2nd notice.  If they don't respond to the final notice within 10 days we send to collections.  However, we do have some providers who like to send anyone over $100 to Accelerator at 60 days.
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PMRNC

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I would remind them that to "threaten" collection actions w/out follow-through is a violation of the FDCPA. You would be amazed at how many consumers have become very savy when dealing with a lot of medical debt. ONE slip can cause you to lose the entire debt owed!

I was ready to sign a client a few years ago who had his OM always include the "stickers" saying it was going to collection after 90+ days, when I was reviewing the practice policies I had asked where the info was on their collection process and the OM simply responded "Oh we don't actually send them, the doctor doesn't want to get into that". Their bills did not even include the mini-Miranda. I didn't sign them as they decided to stay in-house but that same OM called me about 6 months later telling me she should have listened to me as they had a patient with a $7000 debt have it dismissed for violating the FDCPA because they 1) did not follow-through with threats 2) accepted a partial payment of $20 but demanded the full balance on the following statement and 3) Their bills did NOT include the mini-Miranda. This provider did not AUTOMATICALLY become a debt collector in the eyes of the FDCPA, they made themselves one by NOT having a collections practice in place.

If a practice does  not have a policy in place when trying to collect patient balances, there are both state and federal laws that physicians and medical practices have to abide by in communicating with patients because those practices don't have collection agency or policy in place.

Patient's with a lot of medical debt are turning to experts to help them resolve and even wipe out these debts because of FDCPA.



Linda Walker
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www.billerswebsite.com