The Mihalik Blog

Denials and Appeals

For years now, I’ve been reviewing coverage denials issued by health plans and appeals of those denials.  I’ve noticed a few recurrent themes.

 

Providers, such as hospitals and practitioners, often receive denials by not following contractual requirements for prior authorization and concurrent review.

 

Providers often fail to have a denial overturned on appeal by not specifically focusing on the specific reasons for the denial. 

 

I can’t tell you how often I see a health plan receive an appeal that is nothing more than a copy of the medical record without so much as a cover letter.  Just as frequently, I see hospital staff send the same cover letter (with typographical errors and all) for each and every appeal.  I’m not kidding.

 

Providers stand a better chance of successfully appealing a denial if the request for the appeal includes a clear clinical rationale that addresses the specific reasons the denial was issued. 

 

If your denial rate is higher than you’d like or your rate of successful appeals is lower than you’d like, we can help. 

 

The Mihalik Group can manage the entire appeals process.  If you’d like more information on how we do check out our AppealSuccess™ product on our web.  Because 50% of hospitals are currently operating at a deficit, we’ve structured the appeals management service on a contingent fee basis, so there are no out of pocket expenses.  If we’re successful, we get paid—and so do you! 

 

We can also help reduce your denial rate with our DenialPrevention™ program.  We’re happy to start here but I actually think it makes more sense to let us manage your appeals first.  After we’ve done that for a while and have an understanding of what is causing your denials, we can more efficiently analyze internal processes and prescribe solutions.  What’s more, you can pay for the entire DenialPrevention program from the money we recover by managing your appeals.

 

If you want more information you can fill out this form or, for personal attention, you can write to me at gary@themihalikgroup.com.

NCQA Education

On March 30-31, 2009 I’ll be one of several faculty members teaching NCQA’s Introduction to NCQA Accreditation for Health Plans and MBHO’s.  This two-day seminar is designed for organizations undergoing their first NCQA survey or for staff who are new to NCQA accreditation.

 

I’m really excited to be teaching the program in my home town of Chicago.  The venue for the seminar is The Drake, a magnificent historic hotel right on the lake and at the northern end of the Mag Mile. 

If you’re interested in attending the conference you can register here.

 

Looking forward to seeing you in The Windy City…

 

 

HEDIS® Public Comment Open

Last week, NCQA opened the public comment periodon proposed changes to HEDIS 2010. 

 

A new CAHPS measure, Aspirin Use and Discussion, is proposed.  The measure will include rates for Current Aspirin Use and Discussing Aspiring Risks and Benefits (with a doctor or provider).

 

Changes are proposed to the following measures:

·         Years in Business/Total Membership

·         Medical Assistance with Smoking Cessation

·         Colorectal Cancer Screening

·         Appropriate Treatment for Children with Upper Respiratory Infection

·         Use of Appropriate Medications for People with Asthma

 

There also are proposed changes to Technical Specifications and Specifications for Survey Measures.

 

The public comment period lasts until March 17, 2009. 

 

  

 

 

Practitioner Communication Requirements for Behavioral Health

This is the last in a series of blogs on NCQA’s communication requirements.  NCQA did not release MBHO standards for 2009.  The 2008 standards remain in effect.    

 

Items that must be communicated annually:

·         Information about the quality improvement program including goals, processes, and outcomes as related to care and service (QI 2C.2).

·         New preventive behavioral health information to existing practitioners and providers (PH 2A).

Items that must be communicated on joining the network and annually thereafter:

·         The member rights and responsibilities statement (RR 2A.3 and RR 2A.4).

Items that must be communicated once since the prior survey:

·         The organization’s policy prohibiting financial incentives for utilization management decision-makers (UM 4E.1, UM 4E.2, and UM 4E.3).

Items with no specified frequency of communication (I recommend annual):

·         Distribution of the organization’s adopted clinical practice guidelines to all appropriate practitioners (QI 7A.4).

·         A description of the organization’s treatment record policies including requirements for: confidentiality of treatment records, documentation standards, systems for organization of treatment records, standards for availability of treatment records at the practice site, and performance goals to assess the quality of medical record keeping.  A documented process describing treatment record policies and how the information is distributed to practitioners is also required (QI 12A.1, QI 12A.2, QI 12A.3, and QI 12A.4).

·         Information about the medical necessity criteria, including how to obtain or view a copy (UM 2 B.1).

·         The toll-free number to contact staff regarding UM issues (UM 3A.5).

·         The availability of staff to answer questions about the UM process (UM 3A.6).

·         The availability of, and process for, contacting an appropriate peer reviewer to discuss utilization management decisions (UM 7A.1 and UM 7A.2).

·         A description of the process to review information submitted to support a practitioner’s credentialing application, correct erroneous information and, upon request, to be informed of the status of the credentialing or recredentialing application.  A documented process describing the processes and how the information is distributed to practitioners is also required (CR 1B.1, CR 1B.2 and CR 1B.3).

Distribution in a timely fashion following revisions:

·         Revised preventive health information to existing practitioners and providers (PH 2B).

Distribution in a timely fashion following revisions after practitioner or provider joins network:

·         Preventive health information to new practitioners and providers (PH 2C).

Member Communication Requirements for Behavioral Health

My last two blogs have been on NCQA’s member communication and practitioner communication requirements for health plans.  I thought I’d round out the series by doing the same for managed behavioral health care organizations. 

Because of the differences in the Health Plan and Behavioral Health standards, the communication requirements are different. 

 

Items that must be communicated annually:

·         Information about the quality improvement program including goals, processes, and outcomes as related to care and service (QI 2C.1).

·         A description of the availability of an independent external appeals process for utilization management decisions made by the organization (UM 8D.2 and UM 8E.1).

 Items that must be communicated on enrollment and annually thereafter:

·         The member rights and responsibilities statement (RR 2A.1 and RR 2A.2)

·         Information about benefits and services included in, and excluded from, coverage (RR 4A.1).

·         Information about copayments and other charges for which the member is responsible (RR 4A.2).

·         Information about restrictions on benefits that apply to services obtained outside the organization’s system or service area (RR 4A.3).

·         Information about how the member may submit a claim for covered services, if applicable (RR 4A.4).

·         Information about how the member may obtain information about network practitioners, including professional qualifications of primary and specialty care practitioners (RR 4A.5).

·         How the member may obtain inpatient and outpatient services, partial hospitalizations and other behavioral healthcare services (RR 4A.6).

·         How the member may obtain subspecialty care (RR 4A.7).

·         How the member may obtain care after normal office hours (RR 4A.8).

·         How the member may obtain emergency care, including the organization’s policy on when to directly access emergency care or use 911 services (RR 4A.9).

·         How the member may obtain care and coverage when he or she is out of the organization’s service area (RR 4A.10).

·         How the member may voice a complaint (RR 4A.11).

·         How the member may appeal a decision that adversely affects coverage, benefits or his or her relationship with the organization (RR 4A.12).

·         How the organization evaluates new technology for inclusion as a covered benefit (RR 4A.13).

·         The organization’s routine use and disclosure of PHI [What a “routine consent” is and how it allows the organization to use information about the member.] (RR 5D.1).

·         Use of authorizations [The member’s right to approve the release of personal health information not covered by the “routine consent.”] (RR 5D.2).

·         Access to PHI [How the member may request access to his or her personal health information.] (RR 5D.3).

·         Internal protection of oral, written, and electronic PHI across the organization [How the organization protects member privacy in all settings.] (RR 5D.4).

·         Protection of information disclosed to plan sponsors or employers [The organization’s policy on sharing personal health information with employers.] (RR 5D.5).

·         The Explanation text in the NCQA Guidelines requires the organization to communicate its policies that address all confidentiality requirements covered in RR 6 Elements A and C and how they are implemented (RR 5D).

Items that must be communicated once since the prior survey:

·         The organization’s policy prohibiting financial incentives for utilization management decision-makers (UM 4E.1, UM 4E.2, and UM 4E.3).

Items with no specified frequency of communication (I recommend annual):

·         The toll-free number to contact staff regarding UM issues (UM 3A.5).

·         The availability of staff to answer questions about the UM process (UM 3A.6).

 

Member Communication Requirements for Health Plans

In my last blog I discussed communication requirements for members.  This blog addresses NCQA’s requirements for communicating with practitioners based on the 2009 Health Plan Standards.

In future blogs I’ll address member and practitioner communication requirements for managed behavioral health care organizations. 

Items that must be communicated annually:

·         Information about the quality improvement program including goals, processes, and outcomes as related to care and service (QI 2C.2).

Items that must be communicated on joining the network and annually thereafter:

·         The member rights and responsibilities statement (RR 2A.3 and RR 2A.4).

Items that must be communicated annually and whenever changes are made:

·         The organization’s pharmaceutical management procedures (UM 13F).

Initial distribution to all practitioners.  Distribution to all practitioners who subsequently join the network.  Distribution to all practitioners in a timely fashion following revisions:

·         Distribution of the organization’s adopted clinical practice guidelines to all appropriate practitioners (QI 9A.4).

Items that must be communicated once since the prior survey:

·         The organization’s policy prohibiting financial incentives for utilization management decision-makers (UM 4F.1, UM 4F.2, and UM 4F.3).

Items with no specified frequency of communication (I recommend annual):

·         The process to refer members to case management (QI 7B.6).

·         The process to refer members to disease management (QI 8C.6).

·         Information about disease management programs, including how to use the services and how the organization works with a practitioner’s patients in the program (QI 8H.1 and QI 8H.2).

·         A description of the organization’s treatment record policies including requirements for: confidentiality of treatment records, documentation standards, systems for organization of treatment records, standards for availability of treatment records at the practice site, and performance goals to assess the quality of medical record keeping.  A documented process describing treatment record policies and how the information is distributed to practitioners is also required (QI 12A.1, QI 12A.2, QI 12A.3, and QI 12A.4).

·         Information about the medical necessity criteria, including how to obtain or view a copy (UM 2 B.1).

·         The toll-free number to contact staff regarding UM issues (UM 3A.5).

·         The availability of staff to answer questions about the UM process (UM 3A.6).

·         The availability of, and process for, contacting an appropriate peer reviewer to discuss utilization management decisions (UM 7A.1 and UM 7A.2).

·         A description of the process to review information submitted to support a practitioner’s credentialing application, correct erroneous information and, upon request, to be informed of the status of the credentialing or recredentialing application.  A documented process describing the processes and how the information is distributed to practitioners is also required (CR 1B.1, CR 1B.2 and CR 1B.3).

 

Member Communication Requirements for Health Plans

Communicating information to health plan members is a topic that I frequently address in my consulting work with health plans.  I often see a process comprised of multiple silos, where each department in the health plan is responsible for notifying members of the information relevant to that department.  This is definitely inefficient, and can also lead to non-compliance if someone does not take overall responsibility for seeing that all notification requirements are met. 

As a starting point for streamlining the processes for general member communications I draw up a list of all the required general member communication topics.  Such a list follows (based on NCQA’s 2009 Health Plan Standards), along with recommendations on frequency of notification and references to the relevant standard.

In future blogs, I’ll address practitioner communication requirements and also member and practitioner communication requirements for managed behavioral health care organizations. 

Items that must be communicated annually:

·         Information about the quality improvement program including goals, processes, and outcomes as related to care and service (QI 2C.1).

·         A description of the availability of an independent external appeals process for utilization management decisions made by the organization (UM 8D.2 and UM 8E.1).

Items that must be communicated on enrollment and annually thereafter:

·         The member rights and responsibilities statement (RR 2A.1 and RR 2A.2).

·         Information about benefits and services included in, and excluded from, coverage (RR 4A.1).

·         Information about pharmaceutical management procedures, if they exist (RR 4A.2).

·         Information about copayments and other charges for which the member is responsible (RR 4A.3).

·         Information about restrictions on benefits that apply to services obtained outside the organization’s system or service area (RR 4A.4).

·         Information about how the member may submit a claim for covered services, if applicable (RR 4A.5).

·         Information about how the member may obtain information about network practitioners, including professional qualifications of primary and specialty care practitioners (RR 4A.6).

·         How the member may obtain primary care services, including points of access (RR 4A.7).

·         How the member may obtain specialty care and behavioral health services and hospital services (RR 4A.8).

·         How the member may obtain care after normal office hours (RR 4A.9).

·         How the member may obtain emergency care, including the organization’s policy on when to directly access emergency care or use 911 services (RR 4A.10).

·         How the member may obtain care and coverage when he or she is out of the organization’s service area (RR 4A.11).

·         How the member may voice a complaint (RR 4A.12).

·         How the member may appeal a decision that adversely affects coverage, benefits or his or her relationship with the organization (RR 4A.13).

·         How the organization evaluates new technology for inclusion as a covered benefit (RR 4A.14).

·         The organization’s routine use and disclosure of PHI [What a “routine consent” is and how it allows the organization to use information about the member.] (RR 6D.1).

·         Use of authorizations [The member’s right to approve the release of personal health information not covered by the “routine consent.”] (RR 6D.2).

·         Access to PHI [How the member may request access to his or her personal health information.] (RR 6D.3).

·         Internal protection of oral, written, and electronic PHI across the organization [How the organization protects member privacy in all settings.] (RR 6D.4).

·         Protection of information disclosed to plan sponsors or employers [The organization’s policy on sharing personal health information with employers.] (RR 6D.5).

·         The Explanation text in the NCQA Guidelines requires the organization to communicate its policies that address all confidentiality requirements covered in RR 6 Elements A and C and how they are implemented (RR 6D).

Items that must be communicated once since the prior survey:

·         The organization’s policy prohibiting financial incentives for utilization management decision-makers (UM 4F.1, UM 4F.2, and UM 4F.3).

Items with no specified frequency of communication (I recommend annual):

·         The process for the member to self refer to case management (QI 7B.5).

·         The process for the member to self refer to disease management (QI 8C.6).

·         The toll-free number to contact staff regarding UM issues (UM 3A.5).

·         The availability of staff to answer questions about the UM process (UM 3A.6).

Cultural Competency Self Assessment

Are you really interested in developing a culturally competent organization? 

 

Do you need to kick-start a stalled process?

 

Consider a cultural competency self assessment.  This is one of the recommendations that I make when I do presentations on cultural competency in health care. 

 

There are a number of available assessment instruments.  I suggest you take a look at “  The Cultural Competence Self-Assessment Protocol for Managed Care Organizations ” developed under a contract with CMS.  There is also the related “ Cultural Competence Self Assessment Protocol for Health Care Organizations and Systems .

If you want to find other assessments I suggest you start by looking here, here and here. 

 

Among the requirements in NCQA’s draft standards for Culturally and Linguistically Appropriate Services(

CLAS) is—you guessed it—a requirement to conduct an assessment, which states:

  The organization conducts a written assessment that includes the following.

1.      The extent to which cultural competence goals are reflected in its strategic plan

2.      The extent to which cultural competence goals are integrated in its annual business plan

3.      The cultural competence of its front-line staff

4.      The extent to which cultural competence goals are reflected in agreements with  network providers (facilities)

5.      The extent to which cultural competence goals are reflected in agreements with network practitioners (clinicians)

6.      The concordance between languages spoken by the membership and by its front-line staff.

 

Improving Cultural Competency

Among the topics I cover when I do presentations on cultural competency in health care is an overview of steps an organization can take to improve its cultural competency. 

 

The recommendations I make include reviewing and adopting national standards.  This includes accreditation standards but it also includes information from governmental agencies.  Of particular interest is the HHS Department of Minority Health’s “National Standards for Culturally and Linguistically Appropriate Services in Health Care” published in 2001.  For assistance with when to translate materials into languages other than English look at the guidance from the Office for Civil Rights. 

In a previous blogI discussed NCQA’s draft standards for Culturally and Linguistically Appropriate Services.  If you haven’t looked at these yet, I suggest you do it soon as you still have a few days to submit comments as part of the public comment period. 

• Putting each patient’s preferred language and self identified race and/or ethnicity in medical records and information systems.

• Adding a specific category for member/patient, practitioner, and staff complaints related to cultural and linguistic issues—and possibly specific investigation and resolution processes.

• Developing and using defined and formal mechanisms for soliciting community input in program design.

• Developing a strategy to recruit culturally diverse staff.

• Implementing an ongoing staff training program on cultural diversity issues.

• Preparing an annual progress report.

 

The real first step, however, is making an organizational commitment to cultural competency.  In the next blog I’ll discuss how to kick of—or kick-start—the process. 

NCQA’s Draft CLAS Standards and Threshold Languages

I’ve been poring over NCQA’s draft CLAS Standards and found the proposed information on threshold languages to be of considerable interest. 

 

Years ago, when the MBHO standards were new there was a requirement to produce materials in languages other than English whenever 10% or more of the member population spoke a particular language. 

 

NCQA’s draft standards for Culturally and Linguistically Appropriate Services suggest that such a percentage is off by an order of magnitude.  The draft standards indicate that vital documents should be made available in threshold languages as defined below:

For organizations with enrollment of 1,000,000 or more: The top two languages other than English, as determined by either direct or indirect data collection, and any additional languages, when 0.75 percent of the member population or 15,000 members, whichever number is less, indicates a preference for written materials in that language.

 

For organizations with enrollment of 300,000 or more but less than 1,000,000: The top language other than English, as determined by either direct or indirect data collection, and any additional languages, when 1 percent of the member population or 6,000 members, whichever number is less, indicates a preference for written materials in that language.

 

For organizations with enrollment of less than 300,000: Any language, as determined by either direct or indirect data collection, when 5 percent of the member population or 3,000 members, whichever number is less, indicate a preference for written materials in that language.

 

Just as a point of comparison, the California Department of Mental Health defines a threshold language as “a language identified on the Medi-Cal Eligibility Data System (MEDS) as the primary language of 3,000 beneficiaries or five percent of the beneficiary population, whichever is lower, in an identified geographic area, per Title 9, CCR, Section 1810.410 (f) (3).”

While the CLAS standards, once approved, will be voluntary for several years—and when they become required it’s not exactly certain what accreditation and/or certification programs they’ll be found in—I think this definition of threshold languages provides guidance about the direction in which health care organizations, that are serious about addressing issues of cultural diversity and disparities, should move. 

You can send NCQA your comments on the draft CLAS standards.