If your modus operandi is to appeal all denied claims, you may want to reconsider because some claims are not worth it.
“You have to understand the dollars that are in play,” said Ralph Wuebker, MD, who, with Steven Greenspan, JD, offered strong arguments for not rebilling (in certain circumstances) during the Healthcare Financial Management Association’s annual conference in late June.
The two biggest reasons to not rebill some denied cases, said Greenspan and Wuebker, both of Executive Health Resources, a medical necessity compliance solutions company, are time and money.
The Office of Medicare Hearings and Appeals has acknowledged that there is such a backlog of cases waiting for review by administrative law judges that the agency is estimating it will take 28 months to get a case scheduled.
“I’m not sure you want to wait, two, three, five years in order to get those dollars,” said Wuebker.
Most facilities will continue to rebill the majority of denied cases, Wuebker said, and should do so, especially if there is good documentation. However, it is important to identify the small percentage of cases that are not worth it.
“I’m saying you should go through and identify the ones you are most likely to lose,” advised Wuebker. “Take your dollars right now.”
Here’s how you can identify those cases:
- Keep track and notice trends on appeals outcomes to help you decide which cases are not worth trying to appeal. Go through your cases and identify which ones you are most likely to lose. “If you have a low win rate – if you’re only winning 10, 20, 30 percent – goodness gracious, take those dollars now,” said Wuebker.
- Pull in clinical experts in order to better understand how strong your cases are from a clinical perspective.
- Get it right from the start. “It’s not easy, but I think no matter how you cut it up, it’s more economically beneficial to get it right on the front end,” said Wuebker. Understanding the ramifications – the significant dollar impact – of not getting a proper order up front is vitally important, added Greenspan. Instituting processes such as live case review could mean an illegible order can be cleared up before being sent out and denied.
- Cases with quality issues are generally not appealable. It is a better source of time and resources to address the quality issues rather than rebill.
- Have “slam dunk” documentation. “Average” documentation isn’t going to be enough, said Wuebker, because, essentially “you’re going to be considered guilty” until you can prove otherwise.
- Keep track of areas where there is potential revenue leakage. For instance, it’s no longer just a question of inpatient versus observation status; it’s a question of at what point did a case get captured as observation, said Wuebker.