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Frustrated by Managed Care Payment Denials? Learn to Spot Key Landmines

Medicare Advantage (MA) plans, the most common type of Medicare managed care organizations, are an attractive option for healthy Medicare beneficiaries in the community because they often provide a range of supplemental benefits that aren’t available under traditional fee-for-service Medicare, such as vision, fitness, hearing, dental, or other relatively low-cost benefits, points out Maureen McCarthy, BS, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, president/CEO of Celtic Consulting in Torrington, CT.

“However, when Medicare beneficiaries come into a skilled nursing facility (SNF), this is a significant bill,” says McCarthy. “Unlike, for example, a doctor’s office visit where MA plans may pay $100, a SNF stay can cost them thousands of dollars. As a result, payment denials are common—and MA plans sometimes base those denials on rules that are not legitimate. The sentence doesn’t always fit the crime, so to speak, because MA plans may misapply Medicare regulations and guidance from the Centers for Medicare & Medicaid Services (CMS) about Medicare benefits and coverage—essentially make up their own rules—to deny SNF claims.”

Getting a handle on these managed care payment denials is more important than ever because Medicare Advantage (Part C) currently is poised to overtake traditional Medicare (Parts A and B) as the most common Medicare program within the next few years. MA enrollment is increasing by approximately 10 percent annually, according to the Medicare Payment Advisory Commission (MedPAC).

As of this January, 28.3 million out of roughly 64 million total Medicare beneficiaries—44 percent—are enrolled in MA plans, according to the January 2022 Medicare Advantage/Part D Monthly Contract and Enrollment Summary Report. That’s up from 42 percent just last summer, per the June 2021 Kaiser Family Foundation (KFF) issue brief, Medicare Advantage in 2021: Enrollment Update and Key Trends. This increase is consistent with an eight percent increase in the number of MA plans in 2022 compared to 2021. Further, the 2022 stable of MA plans represents “the largest number of plans available in more than a decade,” according to the November 2021 KFF report, Medicare Advantage 2022 Spotlight: First Look.

2021 MA plan penetration surpassed 50 percent in Minnesota and Florida, as well as reaching at least 40 percent in 24 additional states, says the KFF. Within states, penetration varied widely by county. For example, Ohio had statewide MA plan penetration of 45 percent last year, with county-level penetration ranging from 27 percent to 58 percent.

This continued growth means that nurse assessment coordinators (NACs) can’t afford to suffer in silence, suggests McCarthy. “Everyone is frustrated by the unfounded denials in the Medicare managed care space. You aren’t alone in this.”

McCarthy will help NACs identify common types of “bad” claims denials and learn regulation-based strategies to fight denied claims during her session “Managing Managed Care” at Connected | Together, the April 12 – 14 AAPACN 2022 Conference in Las Vegas, NV. This session will address how to handle managed care across the insurance spectrum, including Medicare and Medicaid.

“It would also be fantastic if NACs talk to their billing staff prior to coming to the session and find out if they are getting denials from MA plans and what the reasons are for those denials,” she adds. “That will allow us to expand our knowledge base about what’s happening in the facilities, and we can talk through some of those real-time scenarios as well.”

Some common Medicare managed care issues that McCarthy plans to tackle during the session include the following:

MDSs signed late

The Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual makes crystal-clear that the only way that a Skilled Nursing Facility Prospective Payment System (SNF PPS) MDS counts as a late assessment for billing purposes is when the assessment reference date (ARD) at MDS item A2300 is not set timely within the allowable ARD window, says McCarthy. Note: For details, see page 2-52 in chapter 2 of the RAI User’s Manual, as well as the underlying regulations at 42 Code of Federal Regulations (CFR) §413.343.

“Signing the MDS completion date late—meaning that item Z0500B is not signed within 14 days after the ARD—doesn’t impact payment. Its only potential consequence is as a survey issue under 42 CFR §483.20,” stresses McCarthy. “However, some MA plans are misinterpreting these regulations and denying SNF claims because the MDS completion date was signed late.”

SNF vs. hospital PDPM case-mix groups

When MA plans pay SNFs by Patient-Driven Payment Model (PDPM) case-mix groups, a common scenario that plays out creates a strong ‘us vs. them’ mentality, says McCarthy. “The plan case manager uses the information in the hospital’s medical record to generate PDPM case-mix groups for the resident and preapprove a HIPPS code for the SNF to use for billing,” she explains. “When that resident gets to the SNF, the NAC and the rest of the interdisciplinary team complete most of the MDS based on the resident’s clinical status and needs following admission to the SNF. So, the plan’s PDPM HIPPS code is hospital-driven, and the SNF’s PDPM HIPPS code is SNF-driven—and sometimes the two don’t match.”

Plan case managers who don’t understand the nuances of the MDS or Medicare coverage in the SNF may demand that SNFs bill the PDPM HIPPS code that they initially approved to avoid a denied claim, points out McCarthy. “NACs sometimes feel pressured to change the MDS so that it will generate the requested HIPPS code when that coding is not supported by the documentation in the medical record.”

That is in direct conflict with federal regulation, says McCarthy. “42 CFR 483.20 (g) and (i)(2) require that ‘the assessment must accurately reflect the resident’s status’ and that ‘each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.’”

Newer NACs especially may not realize that anyone who signs at item Z0400 (Signatures of Persons Completing the Assessment or Entry/Death Reporting) is making a legal attestation of accuracy for the sections of the MDS that they sign for, says McCarthy. “A NAC who knowingly miscodes the MDS to get an MA plan’s preferred HIPPS code and then signs at Z0400 that that coding is accurate is falsifying the MDS.”

The result is significant legal exposure for the NAC, says McCarthy. “For example, the penalty per violation in a False Claims Act (FCA) lawsuit is a minimum of $11,803 and a maximum of $23,607 in 2022, plus the statutory penalty of three times the government’s sustained damages.” Note: The original $5,000 – $10,000 penalty is adjusted for inflation since FCA enactment.

Managed care denial notices

CMS requires SNFs to provide MA residents with a Notice of Medicare Non-Coverage (NOMNC) when their Medicare-covered services are ending so that residents have the option to request an expedited determination of the coverage decision. ” SNFs are responsible for both completing and delivering these notices accurately and timely—even though they do not make coverage decisions for the plans,” says McCarthy. “So, if there is a problem with the notice, then the SNF is provider-liable. Many SNFs may not be aware of this issue until they face provider liability resulting from an inaccurately completed notice.”

HIPPS codes for MA plans that pay by levels

SNF billing offices also sometimes misunderstand key rules in fear of denied claims, says McCarthy. “Since mid-2014, all SNF MA claims must include a HIPPS code. However, some plans pay by levels of care vs. PDPM case-mix groups, so no 5-day PPS assessment is actually required. These plans should be billed using whatever HIPPS code is generated on the Admission assessment if there is one, but if the resident is not there for 14 days, no MDS is required, and the claim can be billed with the default code.”

Billers may balk at using the default HIPPS code and say, “You need to do an MDS,” points out McCarthy. “However, the default code doesn’t change the payment from MA plans that bill based on levels. In this situation where the resident is not in the facility for 14 days and the plan bills by levels, the default code is acceptable.” Note: Some MA plans require the PDPM HIPPS and will not accept the default code despite the guidance from CMS to MA plans.

To find McCarthy’s Wednesday April 13 session on the conference schedule and make plans to attend, download the conference brochure here.

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