Briefing: Six Strategies for Successful Appeals Date: 21 March 2007 Time: 1110 - 1200

1. Briefing: Six Strategies for Successful Appeals Date: 21 March 2007 Time: 1110 - 1200

2. Objective • By sharing these six appeal strategies, the attendees will learn • Various means of applying 10 USC 1095 and 32 CFR 220 • Effective communication with private third party insurance carriers • The importance of having a “see it all the way through” attitude toward denials management • The Inside Scoop: What you need to know that you won’t find in the UBO Manual

3. Strategy 1 Strategy #1 • Out of Network…The Denial That Keeps Going, and Going, and Going… • Claim payment is reduced or denied as MTF is considered non-participating or outside of the Preferred Provider Organization (PPO) or network • Appeal using • 10 USC 1095: “No provider of any insurance, medical service or health plan contract….shall operate to prevent collection by the United States” • 32 CFR 220.2: “In any case in which a facility of the Uniformed Services makes a claim or an appeal….any procedural requirement in any third party payer plan must be deemed to be satisfied”

4. Strategy 1 Out of Network (cont’d) • 32 CFR 220.3: “The lack of participation or the absence of a contract is not grounds to deny or reduce payment to an MTF” • 32 CFR 220.4: “Such provisions are not permissible if they are applied in a manner that would result in claims arising from services provided by or through facilities of the Uniformed Services being treated less favorably than claims arising from services provided by other hospitals or providers” • 32 CFR 220.14: “All carriers, including PPO, HMO, EPO, Self-Insured, ERISA and Workers Comp plans are subject to both the US Code and the Code of Federal Regulations” • See example letter and denial and payment EOBs

5. Strategy 1 • Out of Network – The Inside Scoop • Carriers will often change their position about paying the MTF the in-network rate due to • Change in management • Legal department changed their position after denials have been overturned • The employer changed their plan; i.e., from PPO to HMO or to ERISA (Self-Insured) • FEHBP plans pay out of network due to sunset of 32 CFR 220.12 effective 01 Oct 2004 • Per the UBO, these are to be appealed with other parts of 32 CFR that remain intact • Refer denied claims after appeal to base Legal

6. Strategy 2 Strategy #2 • Pharmacy Invalid Denials… They Are Really Toying with Us! • An invalid denial means that the pharmacy carrier (e.g., Medco) will come up with some unknown or vague denial reason • Non Matched product/service ID • Claim Not Processed • Appeal is similar to an out-of-network appeal • Refer to • 10 USC 1095 • 32 CFR 220.3 • 32 CFR 220.4 • 32 CFR 220.14 • See example of Medco denial, appeal letter, and payment

7. Strategy 2 • Pharmacy Invalid Denials – The Inside Scoop • Read the EOB carefully • Call the carrier if a denial reason needs clarification • Consider that the denial could be used for contract providers, which doesn’t apply to the MTF • Talk to a manager about reprocessing your claims in mass; i.e., ask for a mass adjustment • Get specific directions about where to send the appeal and what documents are required • If the carrier maintains the denial, forward to base Legal

8. Strategy 3 Strategy #3 • 99199 – It’s Generic, ButT Go Ahead and Appeal • The DoD implemented use of this code 01 Oct 2004 for APV or outpatient surgical procedures • This is a flat rate assigned by base • In your appeal refer to • 10 USC 1095 • 32 CFR 220.3 • See attached appeal letter, EOB and payment • The Inside Scoop • Medical records may be requested to justify the charges • If it’s already authorized, ask that the claim be reprocessed • If the carrier still refuses, contact the insurance co. pre-authorization dept. for assistance • When all else fails, refer to base Legal

9. Strategy 4 Strategy #4 • Blue Cross…Make It Count! • The facility had not been paid • BC applied a $75.00 co-pay to all clinic claims • A copy of the entire plan was downloaded • An exclusion was found indicating $75.00 co-pay was waived for clinic visits • Claims affected went back 3 years • See appeal letter example and EOBs • The Inside Scoop • In the case of a mass adjustment request or appeal, make sure to contact the manager for the carrier, or the POC for the group • Make sure you have your facts and back them up • Demand that the claims be reprocessed without rebilling

10. Strategy 5 Strategy #5 • Timely Filing…Time Is On Our Side • We bill claims late due to • Late notification from the patient • Verification from the 2569 results in back billing • Attachments, such as medical records not available • Billed to the wrong carrier; i.e., group health insurance is billed and the case is workers’ comp • Systems issues • The example shows • Notification of coverage 2 years after disposition • Laborers H&W (like a self-insured group) billed for inpatient and lacking an authorization • Refer to • 10 USC 1095 • 32 CFR 220.2 • 32 CFR 220.4 • 32 CFR 220.14

11. Strategy 5 Timely Filing(cont’d) • First appeal was rejected • Second level appeal included the medical record and a retro-authorization request • See attached example letters and EOB • The Inside Scoop • Second level appeals are common, keep up the pressure • Remember that 32CFR 220.2(d) states that all requirements are considered met for a claim or appeal made by the United States • Refer claims that continue to be denied to base Legal

12. Strategy 6 Strategy #6 NO! • Last But Not Least…. Don’t Take No for an Answer! • This example involves appeals for one claim • Factors complicating the case • COBRA coverage terminated during the stay • Patient enrolled in Medicaid • Due to the nature of the illness, coverage was disputed • Authorization was disputed by the carrier • This was a inpatient civilian case over $300,000.00 • The appeal referred to • 10 USC 1095 • 32 CFR 220.2 • 32 CFR 220.3 • 32 CFR 220.14

13. Strategy 6 Don’t Take No for an Answer (cont’d) NO! • The second and third level appeal involved a $10,000.00 pre-cert penalty • BC authorized the stay, yet maintained their denial for no authorization • Our documentation showed where BC flip-flopped 7 times before agreeing to cover the self-inflicted injury and to authorize the stay • The documentation we had on file that was handwritten and from CHCS made a difference • We were unable to win the argument about records and complied with their request for review • See attached appeal letters and EOBs

14. Strategy 6 • Don’t Take No for an Answer – The Inside Scoop • When the carrier makes a tremendous effort to deny a claim, you must answer with the same effort • When the carrier makes several errors in their process, you must question their logic • When you have your facts documented with the carrier’s staff name and title, and dates and attach your handwritten and/or system notes to the appeal, this will make a huge difference • Involving the family can be a big plus • Be patient and think about your next move • Know when to forward a denied claim to Legal

15. Conclusion • Conclusion • Remember that 10 USC 1095 and 32 CFR 220 are “THE MOST POWERFUL WEAPONS IN YOUR ARSENAL.” There is no entity in the world that can use these to do battle with insurance carriers • The carriers are not used to our appeals and are confused when we question their tactics • Documentation, Documentation, Documentation • Always escalate your call to a manager, especially when an appeal may involve a large quantity of claims • Be patient and think a problem through • It’s hard to give up the fight, but when you do, your file will have enough documentation and back-up to assist the base legal department with the next phase of the denials management process • e-CFR Web site: www.ecfr.gpoaccess.gov