Home Town HealthDenial Update

August 12, 2015

Agenda• Latest on Estimated Denials• 2016 OPPS Proposed Rule• MedPerformance iMAD

2

Latest on Estimated Denials• From The Advisory Board & HIMSS News– Denials due to just ICD-10 – Expected to increase 100%-200%– 22% of all denials are due to medical necessity– 41% of write-offs are due to medical necessity

3

2016 OPPS Proposed Rule• The Centers for Medicare and Medicaid Services

(CMS) released the 2016 outpatient prospective payment (OPPS) proposed rule, CMS-1633-P

• Final Rule to be issued on or around November 1, 2015

4

• Revises Medicare hospital outpatient prospective payment system (OPPS) which includes:– Two Midnight Rule modifications– Changes in Review – Short Inpatient Hospital Stays– A More Collaborative Approach to Education and

Enforcement

2016 OPPS Proposed Rule

5

Two Midnight Rule Modification• For stays expected to last less than two midnights,

an inpatient admission would be acceptable on a case-by-case basis

• Documentation in the medical record must support that an inpatient admission is necessary

• Case is subject to medical review• Rare and unusual for beneficiary to require inpatient

hospital admission for minor surgical procedure or other hospital treatment that does not span at least overnight

6

Changes in Review Process• Enforcement of the two-midnight rule would shift to

quality improvement organizations (QIOs) from recovery auditors for majority of patient status audits

• Recovery Audit Contractors (RACs) will focus on those hospitals with consistently high denial rates

7

A More Collaborative Approach• Changing the RAC “look-back period” for patient status

reviews to 6 months from the date of service where the claim has been submitted within 3 months from the date of service

• Limits on additional documentation requests (ADRs) that are based on hospital’s compliance with Medicare rules

• RACs must complete complex reviews within 30 days• Failure to follow timeline will result in loss of RAC’s

contingency fee• RACs must wait 30 days before sending a claim to the MAC

for adjustment

8

MedPerformance iMAD• MedPerformance has a powerful and easy to use Denial

Management System “iMAD” that can help you reduce your denials

• MedPerformance can help you with manage your denials with experienced staff

9

iMAD Contact InformationFor more information, please contact:

MedPerformance LLCRebecca Corzine Tarr

Owner(813) 786-8974

Becky@MedPerformance.comwww.medperformance.com

10