Writing an Appeal Letter Lisa Bazemore, MBA, MS, CCC-SLP
Financial Impact • eRehabData Appeals Tracking System: • 1331 denials logged • $24,847,122 dollars in claims • 970 active appeals; $11,424,594 is currently under dispute • 361 appeals have been closed • $6,312,757 was paid; $839,943 was denied
RAC Program • National RAC Program Statement of Work • Can’t request claims prior to 10/2007 • If denial is overturned, RAC loses payment for services • Contractors are: • Region A: Diversified Collection Services, Inc. • Initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and New York • Region B: CGI Technologies and Solutions, Inc. • Initially working in Michigan, Indiana, and Minnesota • Region C: Connolly Consulting Associates, Inc. • Initially working in South Carolina, Florida, Colorado, and New Mexico • Region D: HealthDataInsights, Inc. • Initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona
Levels in Medicare Appeals Process • Additional Development Request • Fiscal Intermediary determines whether or not to pay the claim. • Redetermination • FI considers their original determination based on your appeal. • Reconsideration • The Qualified Independent Contractor considers your appeal. • Hearing • The Administrative Law Judge hears your appeal. • Review • The Medicare Appeals Council/Department of Appeals Board will review the decision of the ALJ. • Next, the Federal District Court will hear you case on disputed claims. *The Medicare Appeals Process is the same for Medicare A and Medicare B claims
ADR • The ADR is a written request from the FI for a medical record which will be reviewed before payment is rendered. • Frequently the ADR comes into the billing office or the medical records department. • Make sure ALL billing and medical records staff are aware of what an ADR is and that they have to notify you (or delegate) before sending out medical records. • Tips: • Documentation is time sensitive • Note the source of the document • Note the reason for the request if one is given • Be aware: • You have 120 days from the date of receipt of the notice. This is presumed to be 5 days after the date of the notice.
ADR • After you have carefully reviewed the FI correspondence: • Follow the directions from the fiscal intermediary completely. • Once the record is copied review it again for completeness and accuracy. • Be sure that each page is copied front and back. • Make a copy of the packet prior to sending it to the FI so you know exactly what the FI had for review. • Send the record to the FI contact as provided on the letter using a delivery method that offers a tracking number.
RAC Exception • RAC Process: • Charts will be requested and reviewed • Determination will be rendered and sent to the provider • The provider has 15 days to rebut the decision of the RAC before the RAC can request funds from the FI • The RAC will consider the rebuttal • If payment is denied, they will notify the FI • Your claim is not a denial until the RAC requests funds from the FI • You have 120 days to appeal the decision from the date of the remittance advice
Redetermination • The Initial Appeal • If the FI does not believe that your documentation meets their criteria for payment, you will receive notification that the claim was denied. • At this stage you will send your record back to the FI with a cover letter stating why you believe this claim should be paid.
Reconsideration • The initial appeal was considered and denied, so now you seek reconsideration with a Qualified Independent Contractor • If the FI rejects your initial appeal, you can appeal the claim at the QIC. • This is the last stage when you can submit new evidence, so consider what input may be available to strengthen your claim.
Letters • You can submit information that will help you make your case for payment. • Types of letters to include: • Letter from the treating physician regarding the medical necessity of the stay (ADR cover letter). • Letter to explain the organization of the medical record being submitted. Include for all appeals. • Redetermination cover letter to rebut the reason for the initial denial. • QIC cover letter to rebut the reason for the initial denial and the denial at the redetermination stage. • Letter from the referring doctor to address the reason for the referral and perceived necessity for rehab. • Letter from the patient or family member to indicate the need and value of the rehabilitation stay.
Appeal Letter • The appeal letter • The body of the appeal letter should contain the following information: • Discuss the reason for the appeal • Support the medical necessity of the claim according to the conditions of participation • Defend each week of care • Explain that the admission was appropriate for your level of care and services were reasonable and necessary • Cite specific Medicare regulations such as the conditions of participation in your letter where applicable
Preparing the Appeal –MD Request Letter • Request help from the doctors: • Prepare a form letter to send to the treating physician to solicit help with the appeals process. • Explain the reason for the FIs request (probe, RAC, program integrity) • Let the doctor know that their opinion makes a difference and carries weight with auditors. • Provide a template of what to include. • Indicate a deadline for their letter to be submitted to you so you can include it with the appeals packet. • Thank them profusely • Be prepared to write the letter for them to sign.
Treating Physician’s Template • Template should include • Summary of etiologic diagnosis/reason for rehab. • Pt. required: • 24 hour availability of rehab MD for _______ • 24 hour availability of rehab nurse for _______ • Multidisciplinary (or interdisciplinary) team approach • Coordinated plan of care • Intense level of therapy services • Pt. demonstrated: • Significant practical improvement • Achieved realistic goals in an appropriate time frame (LOS) • Reason care could not be provided in a SNF
Preparing the Appeal – ADR Cover Letter • Example of MD Cover Letter: • Explain reason for admission • Ms. Example is a 67 year old female who underwent a lumbar decompression and fusion on March 14, 2007 for spinal stenosis and chronic back issues. Her full procedure was that of an L3 through L5 decompression and fusion from L3 to S1, as well as a TLIF at L4-5 and L5-S1. Secondary to this surgery and her premorbid condition, she was noted to have decreased mobility and inability to be independent in ADLs. She had multiple comorbidities, including requiring two liters of oxygen at night chronically, a history of arrhythmias, history of asthma, COPD, and depression.
Preparing the Appeal – ADR Cover Letter • Example ADR Cover Letter: • Review the 8 conditions: • She was evaluated by our preadmission team and was felt to be an appropriate candidate for rehabilitation. The reason for this was related to her recent surgery, long term back issues and multiple comorbidities. It was felt that she required 24-hour availability of a rehabilitation physician, secondary to her respiratory issues, hypertension, history of cardiac arrhythmias and for aggressive pain management. She also required 24-hour availability of rehabilitation nursing to assist in pain management, monitor her respiratory and cardiovascular status, and provide education and training in ADL activities. Due to the complexity of her back surgery and multiple comorbidities, it was felt that she required a multidisciplinary team approach with a coordinated plan of care at the intense level of therapy services that can be found in an acute inpatient rehabilitation facility. It was not felt that this therapy could have been provided at a lesser intense level of care.
Preparing the Appeal – ADR Cover Letter • Example ADR Cover Letter: • Provide Therapy Necessity: • Functionally, at the time of admission, she was noted to be modified independent for eating and she remained so at discharge. Grooming was noted to be supervision and she became modified independent at discharge. Bathing was moderate assistance and was supervision at discharge. Upper extremity dressing was noted to be minimum assistance on admission, modified independent at discharge. Lower extremity dressing was maximum assistance on admission and supervision at discharge. Toileting was moderate assistance on admission and minimal assistance at discharge. With respect to bowel and bladder management, she was at a modified independent level at admission and remained so at discharge. Transfers from the bed to wheelchair were minimum assistance at admission and modified independent at discharge. Toileting and tub and shower transfers were noted to be minimum assistance at admission and supervision on discharge. With regard to locomotion she was noted to be maximum assistance for walking at admission and modified independent at discharge. Stairs were noted to be maximum assistance on admission and modified independent at discharge.
Preparing the Appeal – ADR Cover Letter • Example ADR Cover Letter: • Provide Medical Necessity: • From a medical standpoint, she was monitored closely with respect to her pain management. Medications were adjusted, including adding other modalities such as Lidoderm patch and TENS trials. She also had the addition of Neurontin to address the neuropathic component of her pain. Overall her pain management was improved throughout her stay. Her cardiac status was monitored. She was maintained on her Digitek and Isoptin and blood pressures were monitored as well. Also, she was kept on her antihypertensives from admission. Regarding her respiratory status, she was kept on oxygen at night. She did have frequent documented episodes of desaturation to the mid 80’s on room air with exertion and therefore required supplemental oxygen at discharge. Her depression was monitored as well and she was maintained on Effexor.
Preparing the Appeal – ADR Cover Letter • Example ADR Cover Letter: • Summarize Findings: • Overall, from a medical standpoint with the close medical management and rehabilitation nursing, she did well in that area. It should also be noted that she remained anemic throughout her stay with her hemoglobin both on admission and discharge varied from 8-9 mg/dl. She was treated with iron supplementation and Epogen. From the functional standpoint, as can be seen above, she improved significantly throughout her rehabilitation stay in a relatively short period of time. She was subsequently discharged to home with her family. In my opinion, Ms. Example was treated in the most appropriate setting for her rehabilitation needs and it is not likely that she would have achieved such medical improvements and stability during her rehabilitation course without the assistance of a rehabilitation physician and a rehabilitation nurse. In addition, without the assistance of the multidisciplinary team, I don’t believe she would have had such excellent functional improvements during her stay that allowed her to return back to her home setting within a week.
Preparing the Appeal – ADR Cover Letter • Example ADR Cover Letter: • Provide Additional Resources: • Additionally, we have provided appendices for your reference for the tabulation of therapy minutes (Appendix A) and how our medical records are organized (Appendix B). • Please do not hesitate to contact me if you have any questions or need clarification.
Preparing the Appeal – ADR Cover Letter • Example ADR Cover Letter: Appendix B Excerpt • Before the tabs begin you will find the following: • Inpatient Admission Record – contains demographic information • IRF- PAI (InpatientRehabilitation Facility - Patient Assessment Instrument) • Coding Summary Form • A summary for each tab is listed below • White Tab – Admission • Request for Treatment & Authorization • Advance Directives Acknowledgement Form • Pre-admission Assessment • Referring Hospital Therapy Notes (if available)
Preparing the Appeal –Redetermination Request • After initial determination = denial, write a redetermination request • The request should detail how the claim meets medical necessity for the reasons sited for denial. • Consider presenting proof on all 8 conditions of participation
Preparing the Appeal –Redetermination Request • Redetermination Example Letter: Reasons for Denial: • To Whom it May Concern: • The above referenced claim was denied at determination due to the following four (4) reasons: • The documentation submitted did not demonstrate the intense level of rehabilitation services were provided to the patient. • The documentation submitted did not reflect the degree of physician involvement, which is normally only rendered in a hospital setting. • The documentation did not reflect the need for 24-hour availability of a registered nurse with specialized training/experience in rehabilitation. • The documentation submitted indicated the patient could have achieved his improvement in a less intensive setting. • For your review, enclosed is a complete copy of the medical records, numbered on the lower right corner of each sheet from Page 1 to 593. The Provider respectfully requests that all of these documents be carefully reviewed. When the record is reviewed in its entirety Provider’s claim is properly supported and should be paid.
Preparing the Appeal –Redetermination Request • Redetermination Example Letter: Patient Summary • Patient Summary • In summary, Mr. X is a 92-year old gentleman who suffered a clinical stroke that left him with an objective left facial droop dysarthria, dysphasia and right-sided in-coordination and was admitted to Carolinas Rehabilitation from 11/24/06 through 12/15/06. Premorbidly the patient was in his normal state of health independent with communication cognition, mobility transfers and activities of daily living. His case was reviewed by our consult physiatrist and was determined to be appropriate for inpatient rehabilitation as this is the most appropriate setting for his recovery from his stroke. It was also determined that he required 24 hours availability of a rehabilitation physician as well as a rehabilitation nurse or management in light of his dementia, hypertension, COPD and history of alcohol and tobacco abuse.
Preparing the Appeal –Redetermination Request • Mr. X required and received a comprehensive interdisciplinary stroke specialized rehabilitation program that included rehabilitation patient therapy, occupational therapy, speech therapy, medical social worker, therapeutic recreation services and medical psychology services. A formal team conference led by a physiatrist occurred on a twice weekly basis to insure a program of care. Mr. X participated in an intense occupational and physical therapy program that allowed him to achieve his established goals in a reasonable time. Unfortunately, due to a lack of family support for ongoing assistance, the patient subsequently was discharged on 12-15-06 to a sub-acute skilled nursing facility for ongoing decreased level of supervision and care.
Preparing the Appeal –Redetermination Request • Redetermination Example Continued: Regulation Citation and Rebuttal of Denial: • Denial Rebuttal • 1. The documentation submitted did demonstrate the intense level of rehabilitation services were provided to the patient. • Pursuant to Medicare Benefit Policy Manual, Chapter 1, §110.4.3, the Provider either provided and the beneficiary received at least 15 hours of combined therapy per week or documented that the patient had a condition which prevented such participation in therapy. Furthermore, Medicare Benefit Policy Manual, Chapter 1, §110.1 requires that determinations of medical necessity for IRF services be based upon an assessment of each patient’s individual needs and prohibits denials of payment based on “numerical utilization screens, diagnostic screens, diagnosis or specific treatment norms, ‘the three hour rule,’ or any other ‘rules of thumb.’”
Preparing the Appeal –Redetermination Request • Mr. X required an intense level of therapy services as evidenced by the pre-admission document that can be found on pages 11-17. An intense level of services was ordered in the admission orders on page 50-52. Mr. X participated in therapy as per the grid in Appendix A. He received 1080 minutes in week 1 and 1260 in week 2 and 1260 in week 3. This indicates that Mr. X received more than the required amount of therapy.
Preparing the Appeal –Redetermination Request • Redetermination Example Continued: Regulation Citation and Rebuttal of Denial: • 2. There was sufficient documentation to substantiate close medical supervision by a physician with specialized training or experience in rehabilitation. • Pursuant to Medicare Benefit Policy Manual, Chapter 1, §110.4.1, the Provider demonstrated that the patient required the 24-hour availability of a physician with special training or experience in the field of rehabilitation as evidenced by entries in the patient’s medical record that reflect frequent, direct and medically necessary physician involvement in the patient’s care: i.e., at least every two to three days during the patient’s stay. • Mr. X required the oversight of a rehabilitation physician for management of his functional and medical needs. His medical complications included recent stroke, hypertension, COPD, urinary tract infection, and sleep disturbance. • Mr. X required frequent intervention for the following diagnoses: • Nutritional compromise – we consulted nutrition who assisted with ensuring Mr. X had proper nutritional intake.
Preparing the Appeal –Redetermination Request • Urinary tract infection – we diagnosed this infection on November 27th. A UTI in an elderly person can significantly impair their cognitive and functional condition. It was important to monitor Mr. X closely to ensure he was able to continue to participate in his rehabilitation program. • Hypertension – which was a contributor to his stroke, was an issue during his rehab stay. We monitored his pressures closely and determined an adjustment to his Norvasc dosing was required. Once the dose was adjusted we continued to monitor to ensure the change was effective. We also monitored the patient’s neurological status as he was at significant risk for a second stroke. • Sleep disturbance – we prescribed Trazodone for Mr. X’s sleep disturbance and monitored his response. He needed to have adequate sleep so he could participate in the full benefit of his therapies. Additionally we monitored the amount of time he slept with a sleep log to ensure the treatment was effective. • In addition to managing the medical complications detailed above, I coordinated the plan of care for nursing and therapy.
Preparing the Appeal –Redetermination Request • Redetermination Example Continued: Regulation Citation and Rebuttal of Denial: • 3. There was documentation to validate the requirement of 24-hour availability of a registered nurse with specialized training or experience in rehabilitation. • Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4.2 the facility demonstrated the patient required the 24-hour availability of a registered nurse with specialized training or experience in rehabilitation through the comprehensive rehab nursing documentation found in the Nursing documentation sections as well as in the multidisciplinary team meetings.
Preparing the Appeal –Redetermination Request • Mr. X required the 24-hour availability of a rehabilitation nurse to treat the following: • Skin integrity concerns due to decreased mobility, hemiparesis and nutritional deficits treated by nursing via daily skin assessments, application of prescribed medications and pressure ulcer prevention techniques. • Safety concerns due to weakness, hemiparesis, and cognitive deficits. Interventions included frequent monitoring and assistance with mobility. • Nutrition and hydration issues in light of recent cerebrovascular accident. He was treated with rehabilitation nursing education, nutritional consult and prescribed medications
Preparing the Appeal –Redetermination Request • Knowledge deficit in the areas of nutrition, safety, medication management, complications of diagnoses, advanced directives, pain, patient rights and responsibilities, infection control, and self care. Education on these items was provided during his entire stay and evidence can be found on pages 565-567. • Mobility and self care deficit was treated by nursing by carryover of therapy techniques during outside of therapy. Nursing documentation of therapy carryover can be found in the rehabilitation nursing documentation and in the interdisciplinary Functional Independence Measure document on pages 91-128. • In ordering rehabilitation nursing at Carolina’s Rehabilitation it was known that nursing would perform daily assessment and intervention on fall risk, neurological checks, psychosocial status, respiratory status, cardiovascular status, gastrointestinal status, renal status, bowel and bladder status, mobility, wound care, pain, safety and intake and output monitoring. Assessment and intervention on these items can be found in the daily nursing documentation.
Preparing the Appeal –Redetermination Request • Redetermination Example Continued: Regulation Citation and Rebuttal of Denial: • 4. The documentation submitted indicated the patient could not have achieved his improvement in a less intensive setting. • Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4 Rehabilitative care in a hospital, rather than in a SNF or on an outpatient basis, is reasonable and necessary for a patient who requires a more coordinated, intensive program of multiple services than is generally found out of a hospital. A patient probably requires a hospital level of care if they have either one or more conditions requiring intensive and multidisciplinary rehabilitation care, or a medical complication in addition to their primary condition, so that the continuing availability of a physician is required to ensure safe and effective treatment.
Preparing the Appeal –Redetermination Request • As can be seen from a review of the medical record, Mr. X had significant medical comorbidities prior to and during his rehab admission that required frequent and direct interventions from the physiatrist and rehabilitation nurse. Based on this and his functional needs, it was appropriate to admit him into an acute inpatient rehabilitation facility. When it became apparent his family would not be able to care for him in the community and he no longer needed the 24 hour availability of a rehab physician and nurse he was discharged to a skilled nursing facility as was appropriate.
Preparing the Appeal –Redetermination Request • Redetermination Example Continued: Regulation Citation and Additional Information: • Additional Information • Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4.6 hospitalization after the pre-admission screening is covered only in those cases where the pre-admission screening results in a conclusion by the rehabilitation team that a significant practical improvement can be expected in a reasonable period of time. It is not necessary that there be an expectation of complete independence in the activities of daily living, but there must be a reasonable expectation of improvement that is of practical value to the patient, measured against the patient’s condition at the start of the rehabilitation program. Mr. X’s pre-admission assessment on pages 11-17 indicated inpatient rehabilitation was the most appropriate setting. In rehabilitation his progress from maximal to moderate assistance with most functional activities and mobility progressed to moderate to minimal assistance with most functional activities (please see therapy evaluation on page 485-487 and discharge summary on pages 483-484 for complete functional results) was significant in that it lessened the burden of care to his caregivers.
Preparing the Appeal –Redetermination Request • Pursuant to Medicare Benefit Policy Manual, Chapter 1, § 110.4.7 the most realistic rehabilitation goal for most Medicare beneficiaries is self-care or independence in the activities of daily living; i.e., self-sufficiency in bathing, ambulation, eating, dressing, homemaking, etc., or sufficient improvement to allow a patient to live at home with family assistance rather than in an institution. Additionally the Policy Manual states the aim of the patient’s treatment is to achieve the maximum level of function possible. Review of the physical therapy and occupational therapy evaluation on pages 485-487 shows the patient’s assessment levels as requiring physical assistance with the majority of self care and mobility items. Page 487 of the evaluation shows the goals established as supervision for most functional independence measure items. Achieving this level of independence would have enabled Mr. X to return to the community with supervision.
Preparing the Appeal –Redetermination Request • Redetermination Example Continued: Conclusion: • Conclusion • I do not believe that Mr. X could have received this required care at any other setting other than an acute inpatient rehabilitation facility. The patient, in my opinion, was most appropriately treated at an intensive rehabilitation level of care and, in my opinion, would have more than likely had significant medical complications and worse functional outcome if treated at a lower level of care. • Please also see attached Appendix A - a spreadsheet that summarizes the amount of combined therapy the beneficiary received and Appendix B - a guide to the structure of the medical record. • We respectfully request that you render a favorable decision so that Carolinas Rehabilitation may receive Medicare payment for the above-referenced claim. Should you need any further information or documentation, please do not hesitate to contact me. Thank you. • Respectfully, Winning Doctor, MD Carolinas Rehabilitation
Preparing the Appeal – Supporting Letters • Consider letters from the referring MD and the patient • Referring MD • Send a letter from the attending rehab doctor • Remind them of the patient and your screening process to validate the patient’s selection • Explain the FI’s activity in your facility and area • Let them know how and why you are proceeding with the appeals process • Underscore the importance of maintaining access to care and your facility’s mission • Write the letter for the doctor and list why rehab was necessary
Preparing the Appeal – Supporting Letters • Patient • Send them a letter at denial, assuring them they will not have to pay • Explain the FI’s activity in your facility and area • Let them know how and why (because the denial was an error) you are proceeding with the appeals process • Underscore the importance of maintaining access to care and your facility’s mission • Ask them to write a letter saying why they needed inpatient rehab • Have them send you the letter so you can use in the Redetermination, Reconsideration, and above.
Appeals Tracking • What eRehabData tracks: • Type of request • Dates of correspondence with the FI • Dates of responses from the FI • Reason for denial • Payment/denial amounts • How we report it: • Active appeals • Closed appeals • Total cases in appeal at each stage • Total dollars in dispute at each stage • Total dollars paid at each stage • Total dollars denied at each stage
Appeals Tracking System • Data Repository • Allows you to upload medical records for storage in eRehabData • Can keep records in storage for later review • Others can access records with the proper privileges • Assistance with appeal preparation can occur from remote locations
Words of Wisdom • Appeal all claims • Track all claims • Adhere to time frames • Receive information from Business/Finance Office in a timely manner • Respond in a timely manner with the correct documents • Review carefully all documents from the FI • The ADRs may come in quickly and in large numbers • Have a system to make the process flow smoothly • Appoint a person or two to write the initial appeals to gain proficiency. Proficiency yields efficiency.
Thanks • Thank you to Carolinas Rehabilitation in Charlotte, NC for the examples provided and their willingness to share with all of us what they perfected during their experience with a Fiscal Intermediary Probe Audit. • Thank you to Suzanne Snyder who prepared many of these slides for original use in the Supporting Medical Necessity workshop sponsored by eRehabData.