Note from the speaker: Building an appealability scoring tool

by Tracey Tomak, RHIA, PMP, and Denise Wilson, MS, RN, RRT

Healthcare provider systems have unique sets of payers, payer contracts, payer experiences, and challenges in medical record documentation and billing processes that together can lead to denials. With this in mind, an appealability scoring tool should be unique to each provider. The provider should create the tool by first defining the elements of medical record documentation required for the services provided. Where indicated, payer policy and billing practices that most often result in a successful overturn and those that result in a denial being upheld should also be defined.

When building the tool, begin by considering that the possibility of a favorable outcome on appeal will look different based on a variety of factors, such as the payer and the denial issue. For example, traditional Medicare uses an expectation of the need for at least two midnights of hospital care to define the documentation that would support payment for an inpatient claim. In contrast, a commercial payer may use a commercially available screening tool to define this same documentation. There may not be enough distinction between how the commercial payers view the medical necessity of an inpatient claim to create a distinct tool for each commercial payer. However, for level-of-care denials, there is certainly enough difference between Medicare and commercial payers to consider building one tool specific to Medicare and another tool specific to commercial payers.

Also consider the denial issue. Most providers categorize denials into similar issue categories, such as level of care, medical necessity of a procedure or service, clinical validation, or coding. These denial issues are different enough to warrant an appealability scoring tool unique to each issue. Obviously, the documentation required to support the level of care is different from the documentation required to support clinical validation. Thus, the definitions in each tool will be different. Clinical validation and coding documentation requirements don’t vary much among payers, so one tool that is not payer-specific for each of those issues will typically suffice.

Begin building the tool by defining documentation elements that should be present in the medical record to fully support the denial issue at hand. For example, for a level-of-care denial, supporting documentation for an inpatient admission might include some or all of the following:

• Clear and complete order for inpatient admission
• Hospital stay of more than three days
• Performance of an inpatient-only procedure
• Performance of an outpatient procedure, with subsequent admission to inpatient status due to an adverse event or complication in the peri- or post-procedure period, with clear documentation from the physician of the need for the inpatient admission
• Satisfaction of inpatient admission criteria per evidence-based medicine guidelines or standards of care
• Necessity for a high level of care such as titration of an IV drip, every-two-hour monitoring, or one-on-one monitoring

Editor’s note

Learn more about interdependent revenue cycle metrics and revenue integrity’s role by attending Tomak and Wilson’s session “Appealability: Assessing and Rating a Denial for the Possibility of Overturn” on day one of Revenue Integrity and Reimbursement Strategies: A NAHRI Virtual Event, to be held October 6–8, 2020.

Ongoing learning and peer networking are critical to revenue integrity professionals—now more than ever. The novel coronavirus (COVID-19) has led to unprecedented revenue shortfalls and ushered in a flood of constantly evolving billing and reimbursement changes. Although many revenue integrity professionals continue to work from home and most traditional networking and education opportunities are suspended, NAHRI is committed to providing the focused education and innovative connections they need in a new, virtual event.  This three-day virtual event offers the expert advice and analysis you need to maintain revenue integrity now and prepare for the coming year.

Our expert speakers will cover essential topics, such as charge capture and denials management, and will analyze the impact of recent regulatory changes and related guidance. Each day will close with a live Q&A session featuring speakers from that day’s sessions. Highlights of the agenda include:

• Overview of the 2021 IPPS final rule, the 2021 OPPS and MPFS proposed rules, and CMS’ COVID-19 interim final rule
• Tips for chargemaster maintenance
• Strategies for charge capture
• Key methods to address price transparency requirements
• Methods for analyzing revenue integrity metrics and KPIs
• Current payer audit targets and strategies to manage denials and appeals

View the full agenda here. Learn how you can save on your attendance, including group discounts and membership discounts, here.

About the authors

Tomak is the director of project management and client engagement at Intersect Healthcare in Towson, Maryland. She has more than 20 years of experience in revenue cycle with a focus on hospital coding, charge capture, and denials management. In her current role, Tomak is responsible for coordinating project implementation of Intersect Healthcare’s Veracity® software. She is an active member of IHIMA, serving as the nominating committee chair for the 2018–2019 year.

Wilson is the senior vice president of Denial Research Group – AppealMasters. She has more than 30 years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Wilson has extensive experience as a medical appeals expert and has personally managed hundreds of Medicare, managed Medicare, and commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.