And now, I would like to reintroduce our speakers to get us started with Part 3. Bev Cunningham has been a partner and consultant with Case Management Concepts, LLC, since its inception. Previously, Bev served as the Vice President, Resource Management at Medical City Dallas Hospital, where she was responsible for case management, health information management, patient access, solid organ transplant, and transplant financial services. Bev has been involved in the development of case management for over 25 years, and her areas of expertise include the role of the case manager in the revenue cycle, compliance for case management departments, the role of the physician advisor, and effective denials and appeal management. Bev has achieved ACM certification by the American Case Management Association. And Dr. Tawny Sesta is a founding partner of Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for more than 25 years. Her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations, with measures of patient satisfaction, quality of life, and short and long-term clinical perceptions and outcomes. We thank you so much for both of you being back here with us this morning. We invite you to kick us off with Part 3. Well, thank you so much, Lindsay. This is Bev, and Tawny's here with me. Good morning, Tawny. Good morning. Good morning, everybody. Bev has a little bit of a laryngitis, would you say, Bev? It's definitely a frog sitting in my throat. A frog, okay. I am sitting here with a hot cup of coffee. Well, I think you will power through, because you're that kind of gal, so if at any point you start to sound like an adolescent boy, I'll just jump in. Okay, that sounds great, oh my goodness. Well, you know, we are here to talk about denials and appeals. I guess that's what keeps our jobs secure in case management and frustrates a lot of people. So, I think as we start, though, let's just clarify that health insurance is a for-profit business. Amen. Amen. Their primary function, and they are a multi-billion dollar conglomerate there, their function is to make money for themselves and their investors, and that is true of anyone who sells a product, and so insurance is a product that is sold. There are some entitlement products that are out there, like Medicare and Medicaid, but the vast majority of them, there is a responsibility of the patient that goes along with that entitlement program. I thought it was rather interesting that insurance companies profited more than $41 billion in 2022, and there are some challenges in that their systems are not synchronized, so they may have a third-party payer that's approving or denying your claims. It's really quite the challenge, and I think we're preaching to the choir here, not to anyone who doesn't understand how difficult this process can be, and sometimes it is very difficult to understand why a claim isn't paid. I told you that one of the favorite terms of an insurance company in a denial is lack of medical necessity, and that could just be anything, so we are going to power through this whole side deck and talk about denials and appeals. Okay, so this is one condition that your insurance doesn't cover. They get into the nitty-gritty details. How we get paid is determined by how we manage our medical necessity, our denials, and appeals, and so there are a variety of ways that we get paid, and actually, when you look at it, the DRG case rate group is really you're going to get paid the same amount regardless of how long you keep the patient. Let's say that you have a pneumonia patient in, and they're probably going to stay, I'm just going to guess, three days, but on that third day, the patient says to the doctor, I just don't feel like going home yet, and so the doctor says, oh, that'll be okay, and they stay another day. We get paid the same. The ED may be holding patients, wanting them to move up to the unit, but the DRG case rate is probably where we are at one of the biggest risks. Per diem is that daily rate, and so we're at increased risk of denials with that because the payer is really looking at every single day and every issue, so they want to know what happened over Saturday. They want to know what happened over Sunday. They want to know the nitty-gritty, and they don't want to pay for any delays that we have. The percent of charges we see less now, but it may occur if a patient's bill reaches a certain threshold, and then after that, and this is going to be for the longer stay, high dollar patients, once they reach a certain amount of money in charges, then there's going to be a percent of charges that's paid rather than a DRG rate, and that is just the insurance company acknowledging that that's a high dollar claim, that's a very sick patient, and that they have some responsibility to help pay for that bill. And then your critical access hospitals are cost-based. There's a variety of different ways that you can look at cost base. A percentage of your cost is reimbursed by Medicare. If you have managed care plans or Medicare Advantage plans specifically, they are not required to pay cost base, so that's going to depend on your contract with them. Denial rates are getting higher and higher all the time. So the average denial rate, 12% in the first half of 2022, you can see the trend from 9% in 2016 on up to 12%, and now we're hearing that it's close to 15%. Higher denial rates are seen in the Pacific with a 17% denial rate, Southern a little bit less. Around 82% of denials are potentially avoidable, and one in five of these potentially avoidable ones are not recoverable, and I would guess that many of you would say, well, that one in five is pretty low because I think we are seeing a higher rate than that. And I think these days it's hard to even keep up with the aggregated data about the percentage of denials because they are increasing, and of course we know they also vary by payer. We also know, and I know this will be no surprise to any of you, but registration contributes to the largest percentage of denials, and many of these are frequently not recoverable. We call these, and I think Tony mentioned them in a webinar before, administrative denials or technical denials, and once a technical denial is reached, then it usually stands for the entire bill. So if we don't notify a payer that their beneficiary is in the hospital because we didn't know the correct payer, if we reach beyond that date threshold, then we're not going to get paid for that entire claim, regardless of the fact that it probably or might have met medical necessity. And let's talk about Georgia. I know that some of you may be from other states as well, but since we're working with the Georgia Hospital Association, as you look at this slide, Georgia has some of the highest final denial rates. So the final denial is you get a denial, you appeal, and then a determination is made, and that is called your final denial. Some of the lower rates, you can see Hawaii, Connecticut, Utah, Minnesota, Louisiana, and then the higher rates with Georgia winning a prize on that particular slide. So let's talk about why we have denials. Some denials, like I mentioned earlier, are preventable, but it isn't just denials always that are related to us. So for example, patient access and registration, health information management. We think about health information management not transmitting or sending a medical record to a payer who has made that request. We know that we, as case management professionals, work with some processes that can result in a denial, and then the billing aspect. And so in billing, there is a certain amount of time for every payer that you have to put that final bill in place, and if you miss it, that's another technical or administrative denial, and they will not pay. So of 31% of the denials that are unequivocably avoidable, 43% cannot be recovered. And the question really comes about, why would that be? Is that because we don't have standardized appeal processes? Is that because we are understaffed and we don't really have the time to find each medical record and see if we shouldn't be appealing it? Or Tony, and I think we see this at every hospital we go to, nobody knows where every single denial enters the hospital. Oh my gosh, so many places. So that is a challenge in itself. So prevention. Prevention is the key to avoiding some of that revenue loss, and we can't prevent unless we track our denials, we reported denials, we put action plans in place, and then we begin to make differences. So education and effective collaboration give us some opportunity for presenting some of our, preventing some of our denials, and certainly working with physicians, we're going to talk a little bit in next week's webinar about that, about working with physicians and really helping them understand what's going on when, in fact, they may not even care about understanding the process of that denial. Well it's not football season, but you know, those of you in Georgia, I know, I'm in Oklahoma, yep, we know football, and in football, and actually in any competitive environment, the best offense, or the best defense, excuse me, is a good offense, and the good offense is having a plan of how you're going to deal with those denials and appeals, and understanding what's going on with them. So we are going to talk about the definition of denials management and some of the phases that we go through in denials management, and let's just start with, what is this process? We can influence denial management for sure. So denial management, in that upper part that's underlined and bolded, is the process of monitoring and managing payer reimbursement from pre-admission to post-discharge. So the finance department has in most of them, I'm sure all of them probably now, have in their software, the ability to know that when a payer pays a claim, did that claim actually get paid according to the contract, and if there's a difference, how much is it? And so they are going to be trying to figure out what the difference is. When we're getting claims and we're looking at them, we're trying to figure out on our side, which of these areas is that denial related to? And so when I said that these denials are called medical necessity by the payer, it could be any of these. And so we need to know how we can improve. And even in the hospital, if finance is reporting medical necessity denials, it may indeed not be anything that you as a case manager could impact. So it's important that we review and that we monitor our own claims and we have our own claims database, our own, well, not claims, our own denial database so that we know which denials we're involved in and what we can do about them. So from pre-auth all through the stay, through billing, and then managing them concurrently and retrospectively. And so we know that some of them we may not know until the patient leaves. But the idea is that we would know while the patient is still there, at least what the payer is thinking and be able to respond to that issue. And then lastly, making certain that we have the appropriate care provided at the appropriate level. So let's think about then these three phases of care that can lead to a denial. So before the patient's admitted, while they're here, and while we're doing discharge planning, and then once they've been discharged. Okay, so pre-admission is really all about gatekeeping. We talked about gatekeeping in a previous webinar when we talked about utilization management and where utilization management occurs. And in those same gatekeeping areas is exactly where we want to prevent denials when it is at all possible. Now the next slides, we're going to talk about the admission process. Just that one area where denials can occur. So registration, having an accurate payer information, inpatient only procedure not being billed as inpatient, that's kind of a tough one because the office is submitting a CPT code, which doesn't really always meet the diagnosis, the DRG that we're used to. So that makes a little tough. But in addendum three is the whole list of all the CPT codes that are inpatient only procedures. Not asking a physician for additional documentation before starting a condition code 44 process. One thing we do not want to do is miss an inpatient bill or claim rather than an observation service claim because most of the time there's a difference in those two. And then not including the physician advisor in a condition code 44 and provider liable bill. So when that patient comes in, I'm sure since you've heard Tony speak many times to your group that she's talked about how important it is to do that admission assessment on the day of admission if they didn't come in at 4 o'clock in the afternoon. So we know immediately what's going on with that patient and what that order is. Another reason, though, to have the ED case manager involved and we'll talk again a little bit more about that next week. Hey, Bev, can I just add one thing to the admission? Yeah, it came up last week, but I just wanted to reemphasize that if a patient comes in and goes for surgery that the order for admission should be written, must be written before the patient goes for surgery or that can result in an admission denial. That is a great point. Yeah, so in other words, you don't want to send a patient to the OR without an order to admit them because you're basically doing a surgery without an order to do it. So I just wanted to throw that in there. Thank you. And then a couple of other steps are first that assessment of medical necessity. I mentioned that not being done on admission, not being done appropriately throughout this day. So, you know, one of the examples is that in some hospitals, we have seen that when a Medicare patient is admitted, there is a medical necessity assessment that's done. But the rest of this day, there aren't consistent medical necessity reviews completed. And that's one of our guiding factors as to when that patient should be ready for discharge. And we know that that's certainly the doctors involved in that. But that's part of your rounding and really understanding where is that patient in meeting their medical necessity on day three, four, five, or even further out. And then patient being admitted and discharged before medical necessity assessment was completed. And we talked about that with the self-denial for the traditional Medicare patients. You know, denials take a lot of time. They really, really do. An accurate level of care or status on admission and then the required elements of the two midnight rule that are very important. So when you look at these two pictures, I would just ask you, if you look at the picture on the left, that gorgeous home with the beautiful swimming pool in front of it. And you think about maybe you have a doctor that can write a picture of a patient that is this gorgeous. And it really supports everything that's going on with the patient. And that is such a great position to work with. But you also might have a physician who has a documentation that looks like this on the left. And you go in to meet the patient, and they're pretty clearly a patient in observation services once you've done it. Now, I'm not saying that they're this patient that's in a shack kind of, or looks like a shack to the right, but the doctor's documentation and the record does not necessarily meet what's going on with the actual patient. And that's often where your condition code 44 will come into play. But then if you look at the right side and you think that you can have a physician just give the worst description of a patient, and what a challenge that is. And part of your responsibility is, does the medical necessity match the actual documentation? Does that patient meet it? So, are you really looking at the complete patient or are you just taking bites off of the apple and taking different pieces? We know that utilization management is a lot of work. It is a challenge with the various payers that are out there. Well, Tony, I think my voice has gotten a little bit better as I've been talking, but I'm gonna take a rest now. All right, great. You know, we did have some questions, Bev. Lindsay, should we hold those for the very end or how do we wanna do it today? If you want to, we can go ahead before you wanna start your section, we can go ahead and do that too. So if you wanna do that, we can certainly do that. All right, there's one that in particular, Bev, I thought was relevant. We had one that, let's see, one that came in that says, what are some examples of unavoidable denials? Unavoidable denials, Bev. I was thinking about what I saw that was. Unavoidable denials are when the patient refuses to discharge a patient and they're meeting medical necessity. Well, I mean, that's a good question. Yeah, I was thinking about, you know, you tell the physician the patient should be an observation and he insists that the patient should be admitted, you know, something like that. Yeah, I think when we're thinking about unavoidable, we're thinking about it on our end, there's nothing we could have done. We did everything we could do. That's true, yep, yep. Okay, there's a couple of more. I just wanted to make a comment, excuse me. Yeah, before we answer these, I wanted to just clarify something. Somebody made a comment about, I think Blue Cross Blue Shield maybe in their state is not for profit. So I wanted to explain, for profit means that the company, in this case, the insurance company, provides stockholders, shareholders in the company so people can invest in the company and get returns on those stocks. That's what for profit is. Not for profit, now in New York, just where I live, for profit hospitals are illegal. So all the hospitals in New York are not for profit. That doesn't mean they can't make a profit. It simply means the profits stay within the company. They don't go outside to shareholders. And then the third is nonprofit, which are charitable organizations. So your hospital, depending on where you're located and or the insurance company, since that's what we're talking about, could either be for profit or not for profit. And that simply has to do with whether they, whether you can buy stock into that company. So I just wanted to clarify. They're not being altruistic, Blue Cross Blue Shield. They probably aren't allowed to be for profit in wherever you're located. Okay. Okay, let's see. This says the order to admit this to same day surgery needs to be written before surgery or admit to inpatient order needs to be written before surgery. Any or any surgery has to be written before the patient goes to surgery. Otherwise you are operating on a patient without an order. So you say our process is to admit to same day surgery. The patient then has the surgery. Then after the surgery, the provider writes the order to admit. So is same day surgery in your language, is that inpatient surgery? Meaning the patient comes in the same day for the surgery? Because that's terminology that is specific to certain hospitals. So let's assume it means it's gonna be an inpatient surgery. Then that would be incorrect. And I don't know why one would do that. If the patient is being admitted for surgery, you have to have an order for admission before the surgery. That's just inappropriate. Now, if they're coming in for outpatient surgery, ambulatory surgery, you still have to have an order for the surgery. I mean, we don't do it. We don't give a patient a diet without a doctor's order. You know, I mean, and yet, you know, we do surgery without a doctor's order. So that's my answer to that one. Yeah, there's a follow up here. Yeah, but that one was kind of more, and I'll address that in a second here too. But this follow up here that just says, our process is to admit to same day surgery. The patient then has the surgery. And then after the surgery, the provider writes the order to admit inpatient after surgery. Lots of time, for example, ortho patients come in the same day and then come to the floor as inpatient after surgery. Yeah, no, that is completely incorrect. And I have seen hospitals get denials for that surgery, and that's a big denial. And that's not one you're gonna win on appeal. So yeah, I mean, you're lucky if you haven't gotten any yet, but you will eventually start to see denials on that because, yeah, that's wrong. Okay. So this last one here is more of a question, I think, for the group. And it's asking on admission at the other facilities who are joining today, who is notifying the insurance payer that the patient is in-house? And I see lots of comments here in response. So if you see, Ed, I think it's Jenny that asked that question here. If you would maybe type in the chat in response to her so she can get some ideas, then I think that would be helpful. I think that's the only other question that I see here. Okay, cool. I know a whole bunch of stuff just popped up. I'm gonna stop. I mean, I'm gonna move on, I should say. We'll get to your questions, I promise. Okay, so what are your opportunities for denials while the patient is in the house? So if the patient is physically admitted and all of that, and you have an issue, and you don't provide a physician and a payer peer-to-peer conversation to try to rectify the concurrent denial, when you get that denial and that patient's laying in that bed, you wanna see if you can get that reversed. You don't wanna wait because it's easier usually to reverse it when the patient is still in the hospital. The patient could be out of network and has been admitted but not transferred to the appropriate facility. And that can absolutely happen. And that's, again, a front door issue. Weekend delays, sure, depending on the type of contract you have. So if you have, for example, a per diem contract and you're not providing an acute level of care over a Saturday, Sunday, or holiday for that matter, you could potentially have those days, what they say, carved out, meaning you'll get paid for the other days but they won't pay you for those weekend days. Minimal weekend case management staffing without any vacancy coverage. Okay. Or if you have that skeleton crew, as we call it. Oh, thank you, somebody just mentioned they're absolutely seeing the carve-outs from the per diem payers. Thank you for that. Minimal weekend case management staffing can absolutely lead to a concurrent denial because you may not even catch it while the patient is still there. Clinical information to pay or late, incomplete or not sent at all can result in a denial. Now, when you've got two people covering the whole house on the weekend, are they gonna be able to do every review that needs to be done? You know, hard to say. Or, you know, short staff during the week as well. Not closing out the account after discharge when authorized days for entire stay. I'm sorry, that got cut off a little bit. Not closing out the account after discharge with authorized days for entire stay. So once the patient leaves, you've gotta, you know, close the account and put in the days authorized or report them or however you might do it. Okay, Bev. Yeah, I have to do a little thing here. Okay, sorry. Just use your mouse. Your mouse not working? Okay. More concurrent denial. No, but keep up with the chat. If you go to the chat, Lindsay taught me a little trick. You have to do a little trick, so. Okay, okay. Glad I worked my trick. I do not know the trick, obviously. So more concurrent denial. So the payer delivers the denial while the patient is still in the hospital. Again, that's the definition of a concurrent denial. So you wanna discuss it with the physician, discuss it with the physician advisor if you can't rectify it with the physician. And if you agree with the denial, then you just need to document it in your case management software, but don't write that in the medical record. Understand the denial process from the payer's contract. So if you don't agree with the denial, are you allowed to have a peer-to-peer while the patient is still in the hospital? Again, this gets back to the concept of you guys being able to see the UM portion of your contracts. Will the physician do a peer-to-peer with the payer's medical director? Well, hopefully, and if not, maybe the physician advisor could do it. And then finally, if peer-to-peer available and denial continues, what should you do? You should absolutely appeal during the hospitalization, and if you don't get a resolution during the hospitalization then you should appeal after the hospitalization. So as I said, document UM-related issues in your case management software, but never in the medical record. Now, if you're documenting in an EMR, as I believe I said either last week or the week before, remember that there should be a section in your EMR that is nondiscoverable, and that simply means that should there be a legal action of any sort and a request for the medical record, nondiscoverable portions of the record are not provided to the attorneys that are potentially working on that case. So some of the UM stuff, if you don't have case management software, should be going in that nondiscoverable portion of your medical record, and hopefully it was already set up that way and you guys don't have an issue, and it's usually the quality section of the EMR is where that would go. Keep the physician and physician advisor in the loop anytime you have even a potential denial, and of course an actual denial. So some steps for you for managing the admission and concurrent denials. So you always want to follow that two-midnight rule, and we've emphasized that quite a bit, and that goes back to your ED case management, and as Bev mentioned earlier, we will be going over ED case management as per your request, and it was a good request, next week. So stay tuned for that. It's one of Tony's favorite, it's one of your favorite case management roles, I must say. Well, yeah, I guess. It's just so darn important, and has become even more important over the years, yeah. So from the get-go, the way to manage denials is to have them not happen, obviously. So you want to place the patient right in the correct status and level of care right from the gate, and again, if nobody's looking, then the patient is gonna go wherever the physician chooses. Ensure your physician's plan for hospital days does not extend beyond those approved by the payer. So if you're talking to the physician about the plan, and you've got less approved days, well, then you've gotta have a conversation, and if that physician believes that his expected length of stay is correct or necessary, then you're gonna have to talk to the payer. If that doesn't work, bring in your physician advisor. That could be a big issue. Use your social worker to coordinate complex discharge planning, absolutely, and effective daily walking rounds are absolutely essential today, where you can discuss barriers to discharge or concurrent denials or potential denials. So one thing I don't often hear case managers say when they're on rounds is we have a denial or we are in a situation where we are likely to get a denial. I don't always see that shared, and I think that's because we don't think the rest of the team needs to know that. That's not something they need to worry about. Well, I think they may not need to worry about it, but they need help to do something about it. So if there's a clinical component that can be addressed, they need to know that there's an issue. So that's something you definitely want to share. Okay, let's talk about delays. So during discharge planning, you can have an outcome of a denial when certain things happen. So we have the category of delays. So if you didn't do your assessment early, as Bev said, so discharge planning got delayed, getting started. You didn't get to the social worker early enough or there was a slowness in response from the social worker because of availability. Post-discharge plans weren't discussed early on with the patient and family, and now the family's got to go find a nursing home, and that slows everything down. Decision-making, there may be some really difficult decisions that the family has to make that may need a family meeting with the team, and so that doesn't happen timely. Or the physician is kind of dragging on that discharge. And again, that's something I would have a conversation with the physician about, and then with the physician advisor, and so on and so forth. Delaying post-acute care services, accepting the patient. Okay, well, you want to keep track, obviously, of which ones are the biggest culprits in terms of accepting patients in a timely manner, and kind of stay away from those if you can. Could be over the weekend or Sundays or late in the day or whatever the issue is. If there's a pattern with any one of them, you really do want to kind of shy away because that's really one of those quality, I mean, it's not an official quality indicator, but it's one of those issues that may make you think twice about recommending, so to speak, a particular facility as an example. Okay. Ronnie, if I could just add to this, and this is my slide, and I should have added it when you think about that delays in post-acute care services are often a result of payer issues, especially your Medicare Advantage plans that have a very narrow network. And so you're waiting for them to find a post-acute care SNF, whatever it is, that will accept the patient, and they want to deny you those days. And we have seen that, and that is not right is all I can say, but it does happen. Yes, absolutely. Okay, so let's say now, let's say the patient came in after the weekend, excuse me, over the weekend, and is discharged on Sunday, and there's been no review done over that time because, as I said earlier, maybe you just didn't have enough staff to get to all the reviews. So now you're gonna do a retrospective review on Monday. I always hated Mondays, Bev, for that reason, because my appeal staff would go crazy trying to catch up. Exactly. Yeah, Mondays were a nightmare. I'm sure some of our folks have the same experience. So that short stay admitted patient, the bill wasn't held, because nobody knew about it, and there you go, that's gonna be a denial. And then, of course, all of your retrospective denials come in after discharge. So these are not the concurrency, these are the, am I saying that right, retrospective? Is that the right word? Yeah. I just had a brain fart thing. Feedback to appropriate care. That was very professional of me, I know. Feedback to appropriate care providers regarding the denial should happen, certainly in the retrospective. Collaborate with your physician advisor for any medical record where the patient doesn't meet medical necessity. That is, again, you must escalate those, because you cannot make that final decision as an RN. Aggregate denial information and provide to the appropriate groups. So you should be able to pull together your denial information, and that's one of the problems with having denials living in your finance department's system, because what your finance department does is take any, quote, clinical denial or medical necessity denial, or whatever they call it, and they lump them all together. And as you're gonna see in a few minutes as we go through the different types, that does not give us an opportunity in case management to understand what the causes were, or what subsets all those denials fell into. And in addition to that, in the systems that finance uses, once that bill has been zeroed out, meaning it was paid in full, or it was a write-off, that case falls out of their system, and therefore, you cannot get data going back because you will not have access to all those old cases. So there's a lot of good reasons to have UM, if you really want accurate data, housed in a case management software program. You also want to collaborate. Sorry, I'm sorry. Yeah, I know exactly. It's like the stick when you want to get somebody off the stage. Collaborate with finance, compliance, and patient access to better understand the denial reasons. I did a big thing with patient access because we were getting a lot of registration denials. And we started collecting them. We concurrently sent them to registration as they were happening. But then we also aggregated them. And you know what we found, Bev? We found that a large majority of those registration errors were happening over the weekend. Surprise, surprise. Yeah, and in fact, we were able to get it down to one specific register in particular had more than 50%. So sometimes what looks like a horrendous problem, you could kind of drill down and figure out the root cause and kind of try to get that fixed. Okay, we have a polling question. Okay, I'm going to pull this one up. And then I think we have a couple of questions too, but I'll go ahead and pop this up on the screen. Who coordinates appeals for medical necessity denials at your hospital? Who coordinates appeals? I see lots of you putting in your responses here. Let's see. Let me just make sure I'm scrolling back. I see lots of you who responded to Jenny's question. So thank you all for doing that. And I think that's what you were saying in the chat, Dr. Sesto, were lots of responses to her question last time. Let's see here. There is built-in case management and EPIC where we document everything. Is this wrong? It depends on – could you read that again? I'm so sorry. I didn't hear the beginning. They said there is built-in case management and EPIC where we document everything. Would this be wrong to do that? Well, it depends on where that section is in EPIC. EPIC is working really hard on improving their case management components. So there are – discharge planning should be documented in the EMR. However, some of this UM stuff, particularly on denials and appeals, should not be discoverable. So you have to find out, or maybe you can tell by going into the software, which section of the software it physically is located. That's the only way you'll know if it's okay. I hope I answered that properly. Okay. Let's see. I don't think I see any other questions at this time. So I'll go ahead and end that poll and share those results there. Oh, wow. And we did just have one question come in as I say that. So before you all address this, let me ask this question right here. It says, in your opinion, where is the best place for the utilization review physician advisor to document his review? Well, Bev, would you agree with me that that should be in your case management software? Yes, exactly. And that is – I just – you know, where you said that EPIC is working very hard, and we know they're working very hard and they need to, there are some safe software programs that we have no skin in the game with at all that really allow some very dynamic discussion between the physician advisor and the case managers and the social workers, for that matter, that is in a software that's a nondiscoverable portion, as Tony mentioned. Right, right. Wow. So look at this, Bev. I know. That is tough. Yeah. The director? Three out of 50, the director does the appeals? You are a nurse? Okay. And that's a case manager who has a UR role in addition to other roles. I guess that means 42% finance. Okay. But my question to whoever – five people said finance. I would ask you, is that a nurse in finance? That would be the follow-up question to that. Appeals coordinator is a role that, you know, I've certainly mentioned over time, and this is somebody whose job is dedicated to audit and appeals. So this is a person who's office-based, who manages appeals, manages audits if they come in, and it's this person who's going to be able to aggregate your data on your denials, what types of denials. Also, too, a big thing is interpreting the letters that come in and putting the denial into the right bucket so you can look at it later, continued stay, admission denial, you know, carve-out dates, whatever it is. So that's why we often recommend this appeals coordinator position because they're dedicated to doing this. That's what they do. But we understand it often gets assumed by people who are doing other jobs as well. So I'm sorry for the directors who do it. That's really very difficult. Okay. Thank you. Whoops, I've got to do my trick. Excuse me. There we go. All righty. Avoiding denials. Okay. So as we said, a good offense is a good defense. So you have to have a sense of urgency. So if you've got a concurrent denial, you want to get right on top of it. You have to understand the root cause. So you really do need to dig into those letters. They may be intentionally vague, and you've got to figure out how to interpret them. And we do recommend that that be an RN. And then, as I was just saying, the tracking and trending. If you're not putting the denials into your own database to track and trend that data, then you're not really able to manage the denials as well as you could. Okay. So the other thing is, you know, if you are tracking them, which we hope you will all be doing or are doing, you can keep a record of all your denials by month, and that should include the reason for the denial, was the denial overturned, yes or no. And you can also, your physician advisor, by the way, can also keep some of this denial. When he or she touches a concurrent denial in particular, they can kind of keep the same information, and then you can see what their impact was perhaps on overturning a concurrent denial, who was the payer, who was the provider, and the unit and department. And frankly, in the software, you know, you can make a report that does this or it's probably already in it very easily. And then reporting results. So who do denials get reported to? Finance. I know. Finance clearly has denials. They're not perhaps particularly interested in knowing what kind of denial it was other than a medical necessity. Utilization review committee, absolutely. A monthly denial report should go back to the UM committee, and they can certainly see patterns and trends. Obviously, I think the department and staff and staff meetings, you can go over this stuff. Quality, the quality department. Nursing or other appropriate ancillary departments. Now, they may be sitting on your UR committee, some of those folks, and so they will be able to see them that way. Okay. Would you guys please put your top two to three denial reasons in the chat? That's going to be a lot of chatting. Well, maybe as we go along, we'll kind of see what the benefit is, what each other can see. Yeah, yeah, of course. So here's the most common types of denial. So all denials, pre-cert or authorization was required but wasn't obtained. And, you know, on those offs, it could be some other department or it could be case management. Claim form errors, obviously. Patient data or diagnosis or procedure codes were incorrect. The claim was filed after the payer's deadline. Insufficient medical necessity or use of out-of-network providers. And then on your medical necessity denials, inpatient-only surgeries that were done outpatient and so a denial. Inpatient order with incomplete documentation in the record to support medical necessity. Concurrent stay denials, delays in service, such as we were just discussing. And treatment not provided by or, excuse me, approved by that payer and went ahead and did it. So those are some really good examples and there's certainly many, many more. Okay. Should I go on, Deb, or you want to look at the chat now? Either way is fine. All right. So these are just some more examples. Medical necessity on admission. So this means they're going to deny the entire stay. So admissions and treatments do not meet inpatient criteria. Continued stay denials, patients should have been discharged, no longer meeting acute care medical necessity. You know, I've seen that more often where the physician just is dragging on that discharge. HIN issued incorrectly. So if you give the wrong HIN, and we looked at HINs last week, and or the patient is not able to understand the HIN, well, that may or may not, you won't get a denial, but if you're billing the patient directly, you're not going to get paid. Right, Deb, I mean, that's basically how that goes. Delay in service or treatment. Primarily weekend days when patients are waiting for tests. You know, all the delays that happen more so over the weekend. And for your critical access hospital folks, it could be when the service or consultant wasn't available. And that can happen in a larger hospital as well. You know, oh, it makes me crazy, patient on Friday needs a hip replacement or they broke their hip. Well, that surgeon doesn't operate until Tuesday. And so the patient stays for three days waiting to go to surgery. What we started to do in one of my hospitals was we just said, all right, doctor, if you can't operate today, we're going to find another surgeon who will. Guess what happens? You want to guess, Deb, what happens in that example? Surely they weren't suddenly available to do a surgery. Yes, they suddenly were able to do the surgery. It's a miracle. It is, it was a miracle. Traditional Medicare self-denials, as we have talked about. Payer did not receive clinical information. So that's a technical or administrative. Oh, no, I'm sorry, that's not. Prior auth not completed or patient did not meet observation service criteria. So you begin to see how very specific you can get with a lot of the reasons for these denials and begin to really understand them better. Okay, so did we want to do the chats? Are you ready to do the? Yeah, I think that's a great idea. Well, if Lindsay's ready calculating everything. Yeah, it looks like I've seen a lot of medical necessity here. Medicare managed inpatient did not meet medical necessity, late notification, denial of inpatients for Medicare Advantage plans. Again, lots of medical necessity and late notice, medical advantage denying patient after two midnights and discharge delay, not enough documentation, failure of pre-auth, untimely PA submissions, out-of-network insurance, and then again lots of medical necessity here. That seems to be the most prominent. Can I get one more question out and we'll just keep going? For those who answered medical necessity, can you tell us if that's medical necessity on admission or continued stay, or you don't know because you're using finance? And this is not a criticism. If you don't have software, you don't have it. So a medical necessity. Okay, everybody's answering admission. Continued stay. Okay, that's good. Thank you. I mean, that just gives us a sense of, you know, you knew more specifically what it was, both. Okay, all right, thanks. So no finger pointing. That's not what this is about. This is trying to solve problems. So it's a matter of looking to see where the break is in the process or the issue is in the process. Thank you, Jenny, to correct the process. Okay, so traditional Medicare self-denials that we have talked about before. Let's go through your self-audit process. So if your patient is admitted as an inpatient for either a one- or two-day stay, so that would have to meet, you know, that would be very difficult. So inpatient for short stay discharged before a review was performed. The case manager or whoever is doing that, so for us it might be the audit and appeals person, case manager provides the first level of review. The patient doesn't meet medical necessity per the criteria and then it goes to the physician advisor and or a UR committee member who provides the second level review. Patient meets medical necessity on the second level review, so now it's going to be billed as an inpatient. Now, I certainly hope a short stay like that does meet inpatient criteria. Patient does not meet medical necessity on second level review, then you would bill it as an outpatient. Track self-denials and report to the appropriate people. So that's just like any other denial. If you're self-denying, then of course, you know, you're going to put that onto your table or however you report on this stuff. Okay. Oh, we have a polling question. Okay, let's get that one pulled up here. Do you feel your physicians understand the 2 midnight rule? Do you feel your physicians understand 2 midnight rule? And I see several of you putting in your responses here and then I just see one question that has come in. If you want to address this and while we're waiting on the responses, it asks when you say bill as outpatient, is that the same as observation? It could be observation. It could be just an outpatient. So if you're billing Part B, remember we talked about W-2 or what were the other ones, Bev? 21 or provider liable. 21, provider liable. That's when the patient isn't even in observation. They're less than that and then you're just billing Part B. So it's any outpatient stuff, any outpatient services that are rendered and that would include potentially observation, yes. Okay. I'm going to end this here and show those results. Yay. Okay, well, that's... I think that's not unexpected. No. Not unexpected but unfortunate. Yeah. Oh, dear. Okay. So what can we do about that when the physician... Okay, here we go. I'm sorry. Okay. Well, I was going to say when your physicians don't understand the 2 midnight rule, somebody's got to do some education with them. I mean, that's pretty simple. A question just came in here, Dr. Sessom, that said what level of details do you all recommend that providers know the 2 midnight rule? Well, the physicians in particular need to know their responsibilities as they relate to documentation. The 2 midnight rule is almost completely contingent on appropriate physician documentation and complete physician documentation as we have talked about. So if you go back to that slide, we've got on there for you all the things the physician must document. No, Bev, don't go back. I understand now. Yeah. So, you know, in essence, it's a physician-driven process. And if the physician isn't documenting correctly, then you're going to be out of compliance and it's going to cause a problem. So that's, again, why you need to have case management in the ED doing this so that they can work directly with the physician and make sure the documentation is correct. All right. So you do need to ask. Can I add one thing? Oh, please. Sure. Well, I think the other thing is that physicians need to understand that if a patient is in observation and they have, let's say they have lab tests that came back or a CT scan or whatever, they've had to change the treatment plan and the patient now meets inpatient criteria, go ahead and put them as an inpatient. And I think that sense of urgency that you mentioned earlier, Tony, is something that we need to instill in us and in physicians. Oh, yeah. And let's not forget, the ED physician is focused on emergencies, emergency patients, not on these processes. So, you know, we see a lot of hospitals just say, oh, well, the doctor, you know, he knows, he understands, he'll just do it. And, you know, that's a recipe for disaster. In my, this is my opinion, they're not focused on it, you know, they may not have that sense of urgency like Deb was saying, and I understand that. You've got a car accident that comes in, you know, you're going to, the doctor's going to run to that. But at some point, we've got to get this right documentation and we can be the driver of that and the monitor of that right in the ED, because once that patient leaves the ED, now you've got to go through all this other stuff. Okay, so understanding the denial. So, again, it all starts with that darn letter. Why was it denied? It should be in the letter. Can it be appealed? You have to know whether or not it looks like it's appealable. Did we make a mistake? Did the hospital side make a mistake? And if so, we're probably not going to want to appeal. Finally, appeal if appropriate, but, you know, again, prevention is the name of the game with this. Try to cut things off at the gate, and therefore you won't have problems downstream. So you want to see what was the root cause of the denial. Who impacted the most on that denial? Was it the physician? Now, you know, case management might own, you know, the data, but we're certainly not the only ones who impact on denial. So physician probably is the major contributor to denials. And then any other department, even the family and patient, contract issues and so forth. But, you know, you've got to ask yourself these questions, because, again, it brings you back to what can I do about it? What was the root cause? So how do we know if we made a mistake? Did we make a mistake? Next slide, please. Does the medical record documentation support reimbursement? Maybe we just didn't query the physician for that additional documentation. Is the billing correct for the level of care provided? Is the status inpatient or outpatient correct and matching the authorizations? Did we send clinical information timely by the cutoff time? Did we send the correct records if requested? You know, and if we fell short on any of these, well, okay, then, you know, that may mean we shouldn't appeal. So never assume that the payer is automatically correct, because you got a denial. They may make it sound, you know, very obvious in the letter, but at the end of the day that, you know, as you do a little bit of investigating, you may find they were not correct. And that's why we like to have a dedicated person doing this, because they should become expert in trying to wiggle through and around all of this stuff. And it's time-consuming. And if you guys have three other jobs, you know, are you going to have the time to really do the necessary investigating? So is it a technical or administrative... I'm sorry, technical or medical necessity denial? Technical has to do with you not meeting some obligation of the contract. And medical necessity means the patient didn't meet the clinical criteria for whatever level of care. So they didn't meet that medical necessity, as we've been talking about. So on the technical side, then, the provider, which could be the hospital or a staff member, did not follow the processes or policies for payment outlined by the payer. And that could be in a contract or a provider bulletin. So notification, pre-cert, or failure to provide clinical information, timely filing or billing errors all fall under the technical side. So those are specific. Medical necessity denials, clinical treatments, processes delayed, wrong level of care based on the medical necessity criteria, care that could have been provided at another level of care. So there you go. And that's how you want to look at them. Can the denial be appealed? So does the documentation support the medical necessity for the service that you want to bill? Does the treatment meet the payer's medical necessity guidelines? And again, we always know which criteria the payer is using. Was appropriate clinical information submitted as the physician advisor reviewed the denial and provided support for an appeal? What does the payer contract allow for appeals? And that's really important. Will a physician do the peer-to-peer appeal with the payer if it's allowed? Will the physician advisor do peer-to-peer if the physician will not? And that happens. Or maybe the surgeon's in the OR, or they just don't want to do it. They don't want their day disrupted. They're in their office. Or, you know, the physician advisor may be better suited in terms of what language to appeal with. And then what is the time frame that is allowed for the appeal? If you really believe the issue is not appealable, then you can skip it, you know, not do that appeal. A traditional Medicare self-denial, so if we are condition 121-ing the patient, then we're not obviously appealing that. And then be very objective on how the payer is going to read your appeal letter when you're writing it. So you should have complete identifying information. Next slide. Complete identifying information. Obviously, all the demographics and dates of service and all that stuff. The reason you want to have this case re-reviewed, it's really being re-reviewed in a sense because they've already denied you. And what you expect the outcome to be based on that. And then any other supporting documentation, excerpts from the medical record to support your case. The argument, the applicable guidelines that were used. Unusual circumstances of the case, perhaps. Or medical review literature. Certainly, you can pull that up from your guidelines. Clinical study information, anything like that. Evidence that supports that stay. And for your Medicare Advantage plans and the two-midnight rule and inpatient-only surgeries, quote the appropriate language that supports your case. More on appeal letters, then. State the facts and the denial and the reason for your appeal. Use the name of the appeal that the payer uses. So correlate with what they're calling the denial. Did you mean denial there, Beth? Use the name of the denial? Yes, you're exactly right. I'm sorry about that. All right. No, that's fine. Yeah, so use the name of the denial that the payer uses. So if the payer tells you this is a so-so kind of denial, that's how you want to respond. Chronological and logical flow, but not necessarily a day-by-day review. You don't want to say, on this day this happened, and that day that happened. You want to kind of roll it up a little bit more than that. Include any abnormalities in tests or procedures. Bring that to their attention. Try to be persuasive in your approach, but not argumentative. Include any evidence-based standards, as we just said. And remind the payer that the services were provided to their member and were medically necessary, and so the hospital has an expectation that those services would be reimbursed. Absolutely. Absolutely, Beth. Absolutely. Well, you know what? I do want to mention, at this bottom slide, Denise Wilson started the Association for Healthcare Denial and Appeal Management, and that is, if that's part of your responsibilities, that is a great, you have to join the organization. They do have some free things on their website, but there's a lot of really good information, and they'll do periodic webinars every one to three months. So just, I wanted to throw that in there because I think that's a really good thing to get involved in. Okay. Yeah, that's a great, great resource. I was just like, that's a great resource, yeah. Yeah. The times, they are a changing. So now, do any of you remember Bob Dylan's music? And I was going to ask, okay, I was going to ask the question, you know, he wrote this song, and when he wrote the song about the times they are a changing, it was really a reflection of the generation gap and the political divide that was in the American culture. You know, when I think about now, when we're dealing with contracts and payers and denials, now we're dealing with the gap between what healthcare reimbursement was and what it is now. But would you care to guess what year Bob Dylan wrote the song and saying the times they are a changing? Did you want me to answer that? Oh, well, go ahead. Well, I was going to say 1962. Well, you are so close. It was 1964. So I am impressed because I was trying to guess that, and I'm not certain that I got that right. So here they are. Well, I wasn't born yet, Bev. I just wanted to, you know, say that. Well, yes. Yeah. Well, I think I was born. I might not be able to remember it. So the first thing that's on this slide is know your payer's contract for the case management process. And we are, somebody likes our jokes, Tony. I'm glad. Yeah. We're going to talk about the contract next week. Medical necessity guidelines, peer-to-peer discussion, the appeal process, and the process to send clinical information. But we're also going to talk about why it's important that you leaders of case management are involved in the preparation for the discussion about the contract, and why sometimes you have to sell yourself to your managed care department if you're right, push back, and don't take no for an answer. And that's where the physician advisor can be so valuable. And so there have been a good many discussions by different physician advisors in different chat groups about how they really deal with the medical directors at some of these Medicare Advantage plans especially. And then educating staff and physician advisors on regulatory issues and their contract elements. And that is important. Certainly, every year we get around May-ish, we'll get the proposed rule for the following federal fiscal year, which always starts October 1st. So we're closing down federal fiscal year 2024 right now. But there will be some proposed rules. And then around August, there will be final rules. Very little rules now relate to us. The two midnight rule was moved to instead of the inpatient prospective system, which the reason it's inpatient prospective is that DRGs are going to pay for that patient kind of as a whole. But the two midnight rule was moved to the OPPS, or the outpatient prospective, or outpatient payment system. And then compare any denials to the contract or the provider manual verbiage. So where you said a little over 50% of you, the appeal goes back to the case manager that has these other responsibilities. I just am concerned, and I think, Tony, you voiced that as well, is do they have really time to delve into that? And maybe even the expertise. And it's not that case managers who have all these roles are dumb. We don't mean that at all. We just mean there are so many things that you have to deal with. And so oftentimes, what you have time to do in the day is to go an inch wide and a mile deep, where you're not digging into the details, where a person that's focused on the denials and appeals process, or even the UR process. We saw that some of you are UR nurses. And so that is your role to do the appeal. But you can go a mile deep on that. And so the depth and the ability to push back will surprise the payers. But as Tony mentioned, and I think I said too, that it is a lot of work. So let's talk about managed Medicare Advantage plans and how we're going to deal with their plans now. Can I just say, I love this stuff, because I think we can. I just want you to be able to stand your ground. So number one, know your contract, just the utilization, management, and then know the regulations that support your appeal. So in the Federal Register, you should be able to link on that. But what your appeal will be is there to be held accountable for the two midnight rule. They are to understand that there may be exceptions to the two midnight rule. For example, a patient was admitted as an inpatient with a full understanding or expectation by the admitting physician that that patient was going to spend at least two midnights in the hospital, but got better more quickly. They know that they are supposed to have exceptions. They're supposed to acknowledge those. Now, we have to do our part, for sure. The physician has to document why, but that is one of theirs. The inpatient only list. And then this one, which we haven't talked about yet. The determination of a denial should be made by a physician or other appropriate healthcare professional with expertise in the field of medicine or healthcare that is appropriate for the services at issue. So, wow. That means that perhaps a pediatrician should not be at a payer, should not be issuing a denial for a geriatric patient who has some sort of complex disease process, or a pathologist should not be determining a denial on a surgical case. So, it is fine for you to ask the expertise of the physician who issued the denial. And then understand that if you file complaints, that can influence the Medicare plan behavior. At a recent physician advisor conference, there were a couple of doctors, Dr. Hu and Dr. Caulfield, that actually talked about influencing medical advantage plan behavior. So, let's talk about this part. Be prepared. And you've probably already seen some of these that are going to come from your Medicare Advantage plans. Will our contract and policies and provider handbook override this rule, meaning the two-midnight rule? No. Meaning the inpatient-only surgery? No. Well, your patient did not require hospital care. Okay, let's talk about what part of the hospital care are you saying that the patient didn't require? Because for the two-midnight rule, there is an assumption that the physician that's caring for the patient is the one that should make that determining factor. This patient did not need a second midnight. This is not a high-risk patient to be inpatient. That is not a determination that they can use or a reason that they can use to deny a claim. And we have our own criteria. Okay. You can have your own criteria. Look, look, look, I can't talk. You can have your own criteria, and that is just fine if you have it. But you also have to have that criteria readily available for anybody wanting to look at it. That's another thing that Medicare Advantage plans. That is an expectation that is back on the second bullet, where you can link in and see what that has to say about it. But pick your battles. I mean, you have to decide what are you going to fight over. And if there's any gaps in our care and processes, then we can't expect them to follow the two-midnight rule either. So there you are in battle. Tony, remember the Kevlar vests that we have in stock? Oh, yes. Yes, we still have them for sale. We do have Kevlar vests to protect you from a battle that you might get into. Okay. This is a very in-depth slide, and we're not going to read every part of it. But the question was, when are Medicare organizations able to use internal coverage criteria when making a medical necessity determination for basic Medicare benefits? And so it goes through and it talks about how criteria is established. But here it says in the underlying part, when Medicare coverage criteria are not fully established, MA organizations may create publicly accessible—there's your two key words— publicly accessible internal coverage criteria that are based on current evidence and widely used treatment guidelines or clinical literature as permitted. And then there's your resource. So at the bottom, there's a link. But this is pretty—this is something that the Medicare Advantage plans are hoping that we don't understand, that we're not aware of. And so it's important that we understand this. And it's even more important, at least in our opinion, that you have somebody that understands the rules and regulations of the two-midnight rule for managed care, the Medicare Advantage plans fit, to really focus on these appeals. Don't make frivolous complaints. So Tony had said, don't appeal everything. But when you're complaining about a Medicare Advantage plan. Here are some examples that are non-frivolous. If they say the inpatient only rule of the two midnight rule doesn't apply to them, write down who told you that, you need to have that. If the patient has rehab denied when the patient meets the requirement, you can complain about that. Now, that's not related to the two midnight rule, but we just threw that in. And the physician making the denial determination has no expertise in the patient being denied. So I think you have to, I mean, I think we can't say that a family practice doctor couldn't look at a surgical patient post-op. I think we want to pick our battles. But you can also tell the payer that you're going to file a complaint with CMS. They don't want complaints filed. So there's a regulation, there's a couple of regulations that tell you where all of that information is if you need to go look at it. It's not difficult to find. I went back and looked again myself to make sure that it's something that we all could easily understand. And then there's just some things that I'd already mentioned about a pathologist denying inpatient admission, et cetera. But the last bullet is, this expertise requirement is only for MA plans and not for hospitals. So if you're in a hospital and you have one physician advisor, that may be tough for some physicians who say, well, they don't understand my expertise, oncology, for example, or even surgery as another example. And so oftentimes, if you have a lot of surgeries in your hospital, we will recommend a surgical hospitalist that may work part-time and work in collaboration with your other physician advisor or all of your physician advisors. So do these complaints make a difference? And I just want to be really, really clear that I am not saying go out there and just complain, complain, complain. But CMS does track formal complaints and there is a threshold where those complaints can affect their quality bonus. So they get scores if you happen to have Medicare and you go online or you're helping a patient or someone else, a brother or sister, and you're going online and they want a Medicare Advantage plan, then there are scores for those plans. And you can see that when you're determining which plan you might want to be in. Money is at risk. The MA plan is going to have their attention peaked. Suddenly, suddenly there's an interest. Now, there are regional offices. You can go to the regional offices on that link. And you can also let the patients know that they can file a complaint. And these can be powerful. And they can call 1-800-Medicare, or if they go to the link below 1-800-Medicare, they can do an online link. So just some other examples. I mentioned the denial for rehab. Dr. Ron Hirsch, if you're familiar with him at all, he's like the physician advisor king, maybe. Scott, his website is a great resource. If you just type him in Google, you'll find his website. But he says, ask the patient and family to call their plan and say, you have four hours to approve this. And remember the issues that we get into with these plans is that they have a narrow network often, quite often. And so you have four hours to approve, or I'm going to call 1-800-Medicare and file a complaint. Well, it looks like I left the T off of complaint there. But anyway, just an interesting thing. I don't want everybody to be on the defensive and go out there and put their battle armor on when you don't need it, but also don't give in. Now, if you're in Atlanta, you're in regional four of the CMS regional office, but then the other states, right, you can see are also, excuse me, I'm going to grab a drink real quick. Drink of cold coffee, I might say. But any of these other states are also in region four. But if you go back to, let me see here. You can see my little thing. If you go back to this link, you can also find out if you're in a different state, what your regional office is. So the content of the complaint is that you want to say that there's a plan violation of 42 CFR, you tell where that was, the claim number. Just a brief clinical summary. You are not going to give any PHI, so you're not going to tell the patient's name, the doctor's name, any of this. The time the care began, the note that two midnights passed, any necessary care that received in the hospital, and then request that CMS act on that violation and request a response from CMS. So here we are. The bottom line is that what you need to know when you're dealing with the plans is so important. Know the same things as when you're taking care of traditional Medicare patients. It's nothing different than what Medicare holds itself responsible for in providing care for their patient. I can tell you, and you will probably know this, but the MA plan person will probably not understand any of this. Just be certain that you understand it. Be certain that your physician advisor understands it. Know when the second midnight was going to occur. Know if there were any delays that occurred in the hospital. Don't do a complaint when we cause delays in the hospital. And then track all of your denials and overtones and use them when you have meetings with your payers. And if you're not having meetings with your payers from the utilization management perspective, it's really important that you do that. And then the bottom line, and Tony really talked about this, is how can we prevent similar denials in the future, especially with our Medicare Advantage plans? And I know that we have far more issues with them and with our managed Medicaid plans as well. But how can we prevent those kinds of denials? First, identify the issues and are those trends or is it just more of a one-off? And interview the people that are involved in the denial if it's appropriate. It certainly doesn't hurt to tell the physician, listen, we've got this denial. Is there anything else that you can add? Now, it depends on when that patient was discharged and when that denial occurred. I'm going to guess it takes a while for the Medicare Advantage plans to get their denial to you. But doctors, depending on your medical staff bylaws, can go back and make an addendum to the chart. You oftentimes, they'll probably have to do their discharge summary within 30 days, but there will be a rule in the medical staff standards about when they can deny, excuse me, when they can do an addendum to the chart. That is not something that you want to have happen, but if there truly was something that's missed, then we need to take care of that. Share the results on your denials and your trends and your reasons, make an action plan, implement a corrective process, and then review for outcomes. And I do have to say that we often are great at putting action plans in place and then we move on to the next issue and we really don't follow up to see, did those work well or did they not? So, when you're measuring the success, you're going to measure by a variety of different reasons. Medical necessity denials, you can look at them by payer, by appeal, you can look at them by physician, you can look at them after the appeal, you can look at them if there wasn't a peer-to-peer or after a peer-to-peer. That's always kind of an interesting side-by-side issue to take a look at. And then if you're looking at medical necessity denials by day, you would look at the same reasons. But it is a big challenge and the physician advisor can make a lot of impact on these cases. One of the things that we recommend that physician advisors do is make rounds out on the units while they're out there, talk to the case managers about what's going on and there may be some time for some casual conversations with physicians between the physician and that physician advisor to really understand what they're thinking and to help them understand some of the processes that need to be put in place to meet some of the rules and regulations that are out there. And then you can look at them by denials and by dollars. Toni has done some really good in her outcomes lectures, some really good tables with both denials by case and denials by dollar. And so there are some reasons that you can have that in there. And then we've talked a lot about where to report. Next week, we're going to give you an example of a hospital that we worked with that did a really effective communication where they communicated within a week to the hospitalist group of any denial, any self-denial, any issue that was in a record. Because within a week, they're going to remember that patient. If you go back and talk to them two weeks, three weeks, I mean, sometimes I don't remember what happened last week. They're not going to remember who that patient is possibly, especially if it was a short-stay patient. So it's important. And we'll give you just kind of how that worked. So I don't know if you feel this way, but taking care of denials can be like swatting flies when you should really be shutting a window. Maybe that's just an Oklahoma term. Do you have flies in New York, Tony? Flies? Yeah, some flies. We have a lot of flies in the spring. They all come out. And then in the summer, and they want to come in the house when children leave the doors open. We have ants. Oh, okay. Well, we have some of those too, but probably maybe not to your extent. Okay. I don't know. I put my picture up here. Don't be in denial. Okay. That likeness is so amazing. Oh, thank you so much. Yes. Thank you so much, my ex-friend. Why? You're 20 in this picture. Oh, oh, I see. Okay. Yeah. Okay. So we are going to start looking at some questions and get your input. And it looks to me, I can't see the chat right now, but it looks to me like there might've been an explosion on the chat. It was a bit of an explosion. We love that. Tony and I had a conference call about a hospital that we're working with yesterday, and we talked about how great you guys are. So thank you for your interaction. So maybe, Lindsey, should we just do the first polling question and then we can start addressing any questions if there are questions there? Yep, absolutely. It looks like I'm only seeing, I think, maybe one question for you guys. Can we get some more comments? Okay. There are, but there's a, I'm just scrolling back up here. So there's a comment from, let's see. So Joanna had just let everybody know that she has an order template from a risk management webinar and that she'd be glad to send out. So Joanna, if you want to send that to me, I'm happy to include that. I know there were lots of comments here asking for you to send that out to everyone. If you want to send that to L. Cason, and I'll put that in the chat, you can just send it to me, and then I'll make sure everybody gets a copy of that. I just, I think most of the questions here are just asking for. Okay, and that was Joanna. That Joanna needs something else. Resource. Well, you are on top of it, yes. Okay. I think that somebody wanted to know how many critical access hospitals are on this webinar. Yeah, I saw that question as well. I was going to respond to that in the chat. So Cynthia, I see your question there. I'd have to pull the total registrant report and see, and we have multiple states who are also participating. So it's hard to say with certainty how many critical access hospitals are with us compared to acute care and different types of facilities. But if you all want to respond there in the chat, maybe just let Cynthia know if you're with a critical access hospital or if you have a different designation for your facility, then that would be great as well. I did go ahead and pop that polling question up here on the screen that asks, one of the most important strategies for decreasing denials is gatekeeping of any patient placed in a hospital bed, true or false? And I see lots of you answering here. Oh, comment here that says, Union General in Farmerville, Louisiana, critical access hospital, and we have lots of ants and flies year round. Thank you. I'm sorry to hear it's year round though. Oh my goodness. That's very funny. And I just see one other question that came in that asked if you can give a recommendation for the order of place in the chart when changing from inpatient to observation with Medicare Advantage plans. And currently they have been using patient to be observation status at time of admission, per insurance request and provider approval. Is that okay? Okay, I got a, I'm gonna, let me pull that question up because I gotta, I gotta think on that. Let me see. Yeah, well, I was just gonna say, basically, it should say place and observation. I'm not sure that you need to say per physician request. I mean, every admission is per physician request. So I did just position request or payer request. I don't know. It's here. So it says currently they're using patient to be observation status at time of admission per insurance request and provider approval. Well, you know what, I would not put that in there because don't give them that power. That's my thought. I mean, the physician has the final rule. And so it shouldn't be just because the payer requested it. It should, because that's what the patient met. So, right. Right. Or needs. Yes. Yeah. Okay. I'm gonna go ahead and end this and share that result. Okay. Good job. That is, it's just such an important, such an important part. Okay. Take away. Yes. Thank you. Okay. Who can provide a peer to peer discussion with the payer? Physician, physician advisor, RN, case manager depends on the payer contract. That's a tricky one. I'm just looking here at the chat. I'm going back to the question earlier. It looks like there are several critical access hospitals on here with us. So hopefully that helps. Okay. Yeah. When you ask that question. Yeah. Yeah. I did see somebody from Louisiana in a critical access hospital when I was scrolling through the. We have Iowa, of course, Georgia, Louisiana. Cool. Cool. I love Iowa. I love you, Iowa. I've spoken there a couple of times and everybody was so nice. Thank you. Yeah. I had such an excellent experience in Iowa. Great. Okay. What do we, what do we have? There we go. Okay. Well, certainly the physician can, that is absolutely right. And, you know, depends on the payer contract, you know, that, I mean, I would say either one of these are probably right. The problem is, and as we talk more about contracts is so many of the contracts are silent regarding any utilization management issues. And they say, go to the provider handbook. And I'm probably talking ahead of what I should be talking about when I will be talking about next week, or we will is that in the provider handbook that can be changed at any time, whenever they want to change it. Once it's in the contract, it's there until it gets changed. So there's a lot of reasons why you want more UM stuff in the contract. Okay. That was a good answer. That, that, that, before we go off this, the physician advisor, I mean, is often the person doing the peer to peer. Yeah, they are often as long as, as long as the payer will accept them. That's exactly right. Yeah. Or as long as the physician is often because the physician won't do it, but yeah, they don't want to do it. Who should you share your denial results with? I bet we should have 100% on this one, but we'll see. Oh, I think that was one of my slides. That was one of my slides. They better get it right. Let's see. Yep. Looks like it. Okay. Okay. Okay. All of the above. Certainly to the OR committee. Absolutely. But all of the above. Oh, I was on pins and needles with that one. Okay. Which patient or patients must have a self-denial? So a 75-year-old Medicare Advantage patient, traditional Medicare patient leaving AMA, short stay traditional Medicare patient discharged before a medical necessity review occurred, all observation patients, A and C, or none of the above. things and burying answers coming in here and we can't vote isn't that interesting lindsey will not let us vote oh she's like that you know it's not just because i'm here no no not at all this is a hard one more putting them in here it is a tough one it is i keep hearing myself twice i have an echo echo echo okay here we go there are your results okay now let's talk about this just for a minute so the answer is really none of the above because a short stay pay it's that's i i didn't mean for it to be a trick question but a short stay traditional medicare patient charged before a review occurred doesn't necessarily get a self-denial it's really only the short stay medicare patient that didn't get a review and did not have medical necessity in their record was i cheating by doing that one cheating what do you mean oh i it seems like a trick question and i didn't mean for it to be a trick no but it's a hard question yeah it is a question and when you know because almost half of you answered that it's a short stay traditional medicare patient discharge before the review was done that is absolutely the person that must have a a review to determine if they need a self-denial but right right but we don't know that yet right right you're exactly right okay okay which patients should have their denial appealed all patients with a denial those meeting medical necessity those who did not follow specific rules and regs only those approved by the attending physician b and d b and c c and d i think those who meeting is not a very good uh english it's okay our brain fills in the word when needed thank you yeah yeah i know but jeez those who meeting let's see several of you still putting in your responses here and just that i know we have about 10 minutes or so left and there are a lot of time for today so if you have any kind of final questions for this section go ahead and be typing those into the q a option found there at the bottom of your zoom window or of course you can utilize the chat and type in your questions as well so to make sure that we address all the questions that you have for today's session no okay i've got some good responses here So anybody that should have their denial appealed are really those that meet medical necessity. I think, Tony, I don't know if you want to speak to all patients with a denial. I think you had talked about being really, look, don't just appeal everything. Right, right. That's the essence of that. You really need to do due diligence before you appeal. And that's why it's time consuming, as I said before, and that's why it's better to have a dedicated person. For you guys in critical access hospitals, you might be able to share an audit and appeals person with another critical access hospital because you likely, or at least one other, you likely don't need a full-time person doing this. What's happening in the critical access hospitals is everything's being put on the case manager. So sometimes we have to be a little creative and think outside the four walls of the hospital if possible. So it's just, you know, it's not like bing, bang, boom. You have to do a little bit of homework. So, yeah, I agree. Those who meet medical necessity would be my answer as well. I think it was tricky, Bev, because you had the B and D and the B and C. Yeah, I know, I know. That was, yeah, no, that's okay. All right, we better move along. Yeah, well, this is the last question. Yeah, but then we have chat questions. Which of the following are components now included in a Medicare Advantage plan's responsibilities? So there's a whole list of them. And it's any one of those, all of the above, or all except D. And D would be, let's see, A, B, C, D, the determination of the denial by the person with the expertise in the field. So which of these are the responsibilities of a Medicare Advantage plan? What we hope is that by the end of this you feel a little bit more comfortable with where you need to go or where you're going with denials from your Medicare Advantage plan that go against the CMS rules and regs. I still see a couple of answers coming in here. And just one comment that goes back to the previous polling question that says that we are a critical access hospital and we try to get everything overturned if possible. Good. Well, yeah, if it is legitimate, yes, absolutely. And that's good. No prisoners, right? Okay, I'll go ahead and share those results there. Oh, my goodness, look at you. Their responsibilities are all of the above. So they have to follow the two midnight rule. They have to follow the two midnight rule exceptions. They have to use the inpatient only list. They have to follow the two midnight rule exceptions. They have to follow the two midnight rule exceptions. Determination of the denial by a person with expertise in the field has to occur. And any internal medical necessity criteria must be publicly available. And there's been a lot of discussions on chats on the internets about what is publicly available and really getting that criteria. And it's all of the above. So the vast majority of you all got that right. And those who didn't actually got a component correct, so. Okay, I don't see any pending questions here. So I know we have a few minutes left. If you have, I'm just scrolling through the chat. So if I missed yours, I know there were just lots of comments. Make sure that you're typing that in again for me so that we make sure that we are addressing your questions. I don't think I see any other questions for our speakers this morning. But again. Well, hello. Iowa loves me too, it says. So I just wanted to. Take that in. I did. I just kind of bumped down to this one resource slide because the Association for healthcare denial and appeal management. There's the link to it. And then if you'd like to follow Dr. Ron Hirsch. There's a link to that. So. Perfect. Yeah. Okay, well, I'm just going to do a couple of closing comments, and you'll see the, the resources they're included in the slides. This is a quick just as a quick reminder that you will receive that email tomorrow morning. So if you've joined us for the previous sessions, this is how the process works. So hopefully you have been receiving these emails throughout the series. But that email does come from education. No reply at zoom dot us. And so if you have not been receiving those emails, it is quite possible that because it's coming from that zoom email that it's getting called in your spam quarantine junk folders. And so if you don't see that in your inbox in the morning, and you'd like to go back and access the recording, you can do so by just using the same zoom link that you use to join us for the live presentation to also access that recording. So you will just need to click on the zoom link and type in your information that will prompt an email to come to us. And then we will approve your recording access request and we typically do so very quickly within a few moments of receiving your request. But we asked you give us one business day, and then you will have full access to the recording of today's session for 60 days and then that also applies to the previous two sessions. So if you need to go back and access a recording of another session in this series, you will have 60 days from the date of that live session to access the recording. And then also included in that email tomorrow morning will be a link to the slides, but I did go ahead and provide that link there for you in the chat now as well. And then we have received a couple of questions from you all. Excuse me, after the each presentation that we've had that you want to send over to our speakers so you do see their contact information here on the screen. But you can always send that to education at gha.org and we'll be happy to pass those questions along to our speakers as well. Okay, I see someone send out all who are attending with their emails and states. Unfortunately, Cynthia, I'm not able to pass along the contact information of all of the registrants here today. But if you have any particular questions that you know you need to get to us, I'm happy to help in another way, but we just are not able to send out the contact information for the registrants. Hi, I don't see any other pending questions here. But again, you can always reach us at education at gha.org. We'll be happy to help in any way that we can. And we have one more session in our four part series next week. And so we just look forward to having you all back with us then. And I hope you all have a wonderful afternoon and a wonderful weekend. Thank you so much, Dr. Sesta and Bev. And we look forward to having you back with us to close out our series next week. Thank you so much, everybody. Bye.

healthcare denials

appeals

proactive approach

data tracking

collaboration

root causes

medical necessity

out-of-network insurance

Medicare Advantage plans

two midnight rule

denials expertise

internal criteria

preventing denials

handling appeals

payer contracts