1 Appealing Claim Denials Janet McCarty American Speech-Language- Hearing Association
2 Today s Agenda How to Respond to Health Plan Denials Understanding Medical Necessity Documentation Needed Sample Appeal Letters
3 Prepare A Claim Provide patient information Provide a diagnosis using ICD-9 codes Provide a treatment code using CPT codes Be able to support code assignments with patient history, physician referral notes and evaluation notes Obtain patient permission to supply health plan with information
4 Waiting For A Decision Most states require health plans to pay or deny a claim within 30 to 60 days Notify the state insurance commission if health plans fail to make timely decisions (
5 Claim Denied.Now What? If you don t agree with the decision, consider appealing the denial.
6 Appeal A Claim: Step 1 Review the patient s insurance policy for coverage information. Does coverage support payment? Review the explanation of benefits (EOB) for denial status and reason.
7 Appeal A Claim: Step 2 If coverage language supports payment, write an appeal letter describing the disorder, its medical nature, and reference the coverage policy paragraph that shows how your treatment fits coverage criteria. Sample appeal letters available at sement/private-plans/appeals.htm
8 Reasons For Denial Not medically necessary Treatment is investigational Not a covered service Local public school provides treatment Provider status not recognized Treatment is educational/developmental in nature
9 Health Plan Disputes by Type Medical necessity disputes accounted for 37% of appeals Contractual limits of coverage accounted for 36% of appeals Disputes over access to out-of-network services accounted for 19% of appeals (Journal of the American Medical Association; February 2003)
10 Health Plan Disputes by Type Among disputes over contractual limits of coverage, 61% of the cases focused on speech therapy, physical therapy, foot orthotics, dental care, alternative medicine, investigational therapies, and infertility.
11 Rate of Overturn of Disputes Contractual disputes were overturned 33% of the time Out-of-network disputes had a 35% rate of overturn Medical necessity disputes had the highest rate of overturn at 52%
12 Medical Necessity Disputes However, these medical necessity disputes were concentrated on relatively few services, such as surgery for obesity and breast alterations. These disputes highlight the need for more frankness about health care that is medically necessary and the role of health insurance.
13 Medical Necessity Speech-language pathology and audiology services must be viewed as treatment of impairments, and not as a quality of life issue. Treating an individual s speechlanguage, hearing, or swallowing disorder improves health status, and therefore, is medically necessary.
14 Medical Necessity Definition is often vague Each health plan defines medical necessity
15 Medical Necessity Defined Medicare defines medical necessity as: a service that is reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member. The service must be provided within generally acceptable professional medical standards.
16 Why Speech-Language and Audiology Services Meet the Definition of Medical Necessity These services are medically necessary to treat speech-language, swallowing, hearing and balance disorders, many of which have a neurological basis and result from injury, illness, or disease. Medical necessity takes into consideration whether a service is essential and appropriate to the diagnosis and/or treatment of disease or injury.
17 Speech-Language and Audiology Services Are Medically Necessary (con t) Stedman s Medical Dictionary, 24 th Edition, defines illness and disease as a disorder of body functions. Loss of hearing, impaired speech and language, and swallowing difficulties all reflect a loss of body functions and services to treat such impairments must be regarded as meeting medical necessity.
18 Appealing a Verbal Apraxia Denial: Establishing Medical Necessity Case Study
19 Provide Supporting Evidence Verbal apraxia is not a developmental delay, but rather an issue of health and normal physiological function It is a speech disorder that is neurologically based Child has limited control of speech muscles
20 Provide Supporting Evidence Recent scientific findings shed light on the cause of pediatric verbal apraxia. British neurogeneticists identified a gene mutation that appears responsible for verbal apraxia (Nature, 413, ; 2001). Studies suggest basal ganglia, a brain region that controls movement, may be different for those with verbal apraxia.
21 Appealing a Cognitive Rehabilitation Denial: Treatment Is Investigational Case Study
22 Why Do Health Plans Say Cognitive Rehab is investigational? BlueCross BlueShield Association Technology Evaluation Center issued a report in Dec stating cognitive rehab services were investigational and therefore not covered. Other independent BCBS s adopted this policy.
23 Challenging A Health Plan ASHA provides support for cognitive rehab (NOMS data, letters to BCBS) Treatment efficacy reports Medicare recognizes SLP s role NIH consensus statement supports cognitive rehab Recent independent review of denial in MT supports cognitive rehab
24 ASHA NOMS Data A large percentage of patients with TBI who received speech-language pathology services made significant gains on the Functional Communication Measures (FCMs). FCMs are 7-point rating scales ranging from least functional (Level 1) to most functional (Level 7) that measure improvement.
25 ASHA NOMs Functional gains were demonstrated by: 81% of patients treated for memory 82% of patients treated for attention 83% of patients treated for pragmatics 80% of patients treated for problem solving
26 Research Supports Cognitive Rehab In an article entitled Evidence-based Cognitive Rehab: Updated Review of the Literature From , published in Archives of Physical Medicine & Rehabilitation (Aug. 2005), the authors report substantial evidence to support cognitivelinguistic therapies for people with TBI or stroke.
27 NIH Support Cognitive rehab is endorsed by the National Institutes of Health (NIH) consensus panel, which notes existing studies that support this treatment, even though research in this area is exceedingly difficult to conduct.
28 Support From U.S. Dept. of Defense & Dept. of Veterans Administration Together form the Defense & Veterans Brain Injury Center (DVBIC) DVBIC actively engaged in innovative/cutting edge rehab of brain injured veterans Conducts clinical research Brain injury becoming signature wound of Iraq war
29 Why Is Research Lacking for Cognitive Rehab? Only controlled research can sort out the impact of treatment vs. spontaneous recovery, but it is complex and costly It is a challenge to define the active ingredients of an interactive therapy provided by a clinician and the most appropriate control or comparison condition Gathering a sufficient # of patients with similar cognitive characteristics is difficult
30 However.. The absence of firm efficacy data is not evidence of the ineffectiveness of cognitive rehab. John Whyte, MD, PhD, Promoting Research in Cognitive Neuroscience and Cognitive Rehabilitation (Health Policy Newsletter, Vol. 18, #3, Sept. 2005).
31 Cognitive Rehab Denial Overturned You and your patient can win! An Independent Review Organization overturned a BCBS of Montana denial for cognitive rehab services for a 38 y/o patient with head injury as the result of a car accident.
32 Denial Overturned. After a year of denials and appeals, the independent reviewer concurred with ASHA s position and required BCBS of MT to pay for patient s treatment.
33 Health Plan Says: Get Speech Therapy from the Local Public Schools Q. Can a health plan say this? A. Probably. Health plans often have a government agency exclusion clause in the contract. If a state/federal government agency provides the needed treatment (schools), then that treatment is excluded from coverage. ASHA is developing a strategy to prevent health plans from doing this. It will be aimed at state legislative efforts.
34 Documentation Needed Q. What documentation must I provide the health plan? A. Whatever is necessary and reasonable to review a claim. Documentation requirements can vary and each plan may specify unique data. Typically, health plans request only minimum information. Evaluation reports and weekly notes are reasonable.
35 Documentation Always link the communication disorder to a medical diagnosis when appropriate, including remarkable medical history. This helps establish medical necessity.
36 Appealing Beyond the Health Plan: External Claim Review Consider external claim review (independent review) after exhausting all appeal levels of health plan If a patient prevails at the external claim review level, health plans must pay for the treatment, and a precedent is established.
37 External Claim Review ASHA strongly promotes the use of the external claim review process 42 states have an external review process Go to to get information about each state s procedure and contact points.
38 Payment Tips Review the patient s policy for coverage Use terms that are medically oriented (evaluation, diagnosis, treatment, condition) Submit correct ICD-9 and CPT codes, physician referral, progress notes, goals and discharge plans Educate payers about your services and new procedures
39 Appealing A Claim Questions? Do you have a specific case to present? Successful appeal to share?
MEDICAL NECESSITY FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY SERVICES 2004 General Information Medical Necessity For Speech-Language Pathology And Audiology Services is published by the American Speech-Language-Hearing
Insurance Tips The information below is designed to provide an overview of how to obtain insurance coverage for speech-language pathology (speech therapy) and audiology services. The American Speech-Language-Hearing
Billing, Coding, & Calculating Fees: Finding Success Janet McCarty American Speech-Language-Hearing Association Today s Agenda BILLING: Learn how to bill for your services. CODING: Learn the codes that
MAKING SENSE OF YOUR HEALTH INSURANCE PLAN SPEECH, LANGUAGE, HEARING BENEFITS Did you know? Hearing loss is the number one birth defect in the United States. Two out of every 10 children will have some
Adult Speech-Language Pathology Services in Health Care How do speech-language pathologists (SLPs) help people? SLPs work with people who have trouble speaking listening reading writing thinking swallowing
SAM KARAS ACUTE REHABILITATION CENTER 1 MEDICAL CARE Sam Karas Acute Rehabilitation The Sam Karas Acute Rehabilitation Center is a comprehensive and interdisciplinary inpatient unit. Medical care is directed
New York State Benchmark Plan Recommendations Introduction The Patient Protection and Affordable Care Act (ACA) includes Rehabilitative and Habilitative Services and Devices as one of the ten categories
Frequently Asked Questions About Your Hospital Bills The Registration Process Why do I have to verify my address each time? Though address and telephone numbers remain constant for approximately 70% of
West Penn Allegheny Health System System Compliance Department Medical Necessity and Billing for Inpatient Rehabilitation Lessons Learned from an Inpatient Rehab Unit Billing Audit 2006 HCCA Compliance
Responding to the Demand: SLPs in the VA By: Micaela Cornis-Pop, Ph.D. Rehabilitation Planning Specialist VACO Rehabilitative Services 1 Responding to the Demand! 246 clinical SLPs! 10 research SLPs! 58
Audiologic/Aural Rehabilitation: Reimbursement Issues for Audiologists and Speech- Language Pathologists What is covered here New audiologic/aural rehabilitation (AR) codes Role of audiologists and SLPs
Running Head: SPEECH-LANGUAGE PATHOLOGIST 1 Job Title Speech-language pathologist General Overview Speech-language pathologists assess and treat individuals affected by a wide array of communication and
Physical & Occupational Therapy Authorization FAQs 1. What are the authorization requirements for the UM program? The utilization management program requires providers to obtain authorization after the
National Stroke Association s Guide to Choosing Stroke Rehabilitation Services Rehabilitation, often referred to as rehab, is an important part of stroke recovery. Through rehab, you: Re-learn basic skills
Speech Language Pathologist Overview The Field - Preparation - Day in the Life - Earnings - Employment - Career Path Forecast - Professional Organizations The Field Speech-language pathologists, sometimes
Health Insurance Appeal Guide 03/14 Filing a Health Insurance Appeal Use this reference guide to understand the health insurance appeal process, and the steps to take to have a health plan reconsider its
NC WORKERS COMPENSATION: BASIC INFORMATION FOR MEDICAL PROVIDERS CURRENT AS OF APRIL 1, 2010 I. INFORMATION SOURCES Where is information available for medical providers treating patients with injuries/conditions
Adult Aphasia What is aphasia? Aphasia is a language disorder. It can cause problems with understanding speaking reading writing Thinking (cognitive) skills are usually good. What causes aphasia? Aphasia
Comments and Responses Regarding Draft Local Coverage Determination: Outpatient Physical and Occupational Therapy Services As an important part of Medicare Local Coverage Determination (LCD) development,
I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.20 Page: 1 of 11 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)
Guidelines for Medical Necessity Determination for Speech and Language Therapy These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine
Inpatient Rehabilitation Facilities (IRFs) [Preauthorization Required] Medical Policy: MP-ME-05-09 Original Effective Date: February 18, 2009 Reviewed: April 22, 2011 Revised: This policy applies to products
Update: Embracing Change March 23, 2013 Jerry A. Johnson, M.D. Executive Medical Director National Healthcare Reform State of Michigan Regulatory Reform Autism Mandate Direct Pay Initiative Medical Policy:
MEDICAL POLICY SUBJECT: COGNITIVE REHABILITATION PAGE: 1 OF: 5 If the member's subscriber contract excludes coverage for a specific service it is not covered under that contract. In such cases, medical
SUMMARY OF MARYLAND STATE EMPLOYEES & RETIREES BEHAVIORAL HEALTH PLAN January 1, 2014-December 31, 2014 Call APS Healthcare Toll-Free: 1-877-239-1458 Customer Service for Hearing Impaired TTY: 1-877-334-0489
Carol Novak, RN, CHC Martin Yuson, DPT, JD Tips for Effective Auditing/Monitoring of Medicare Documentation for OT, PT and Speech 4/24/2013 The wonderful thing about standards is that there are so many
Handbook for Providers of Therapy Services Chapter J-200 Policy and Procedures For Therapy Services Illinois Department of Healthcare and Family Services CHAPTER J-200 THERAPY SERVICES TABLE OF CONTENTS
Eileen M. Brann, Ph.D., M.Ed., CCC-SLP 1 University Parkway University Park, IL. 60684 Phone: office: 708-534-4594 Email: email@example.com Education Ph.D., Special Education 2005-2013 University of Illinois
House Bill 429 (AS PASSED HOUSE AND SENATE) By: Representatives Stephens of the 164 th, Wilkinson of the 52 nd, Shaw of the 176 th, Dollar of the 45 th, Rogers of the 29 th, and others A BILL TO BE ENTITLED
Community Plan KanCare Program Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide Doc#: PCA15026_20150129 UHCCommunityPlan.com Welcome to UnitedHealthcare This administrative
Chapter 4 Health Care Unit 1: Care In This Unit Topic See Page Unit 1: Care Care 2 6 Emergency 7 4.1 Care Healthcare Healthcare (HMS), Highmark Blue Shield s medical management division, is responsible
POLICY TITLE: CRITERIA UTILIZED IN DETERMINATION OF MEDICAL NECESSITY. POLICY STATEMENT: MAHP utilizes evidence based medicine in its decision making process. This policy is to establish and maintain medical
NEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES POLICY GUIDELINES Version 2015-1 Page 1 of 11 Table of Contents SECTION I REQUIREMENTS FOR PARTICIPATION IN MEDICAID 3 QUALIFIED PRACTITIONERS. 3
Rehabilitation Reimbursement Update By: Cherilyn G. Murer, JD, CRA Introduction The Centers for Medicare & Medicaid Services (CMS) and legislators in this country remain dedicated to ensuring that beneficiaries
Provider Specific Policy Manual Revision Table Revision Date Sections Revised Description 5/1/04 New Manual Prior to 5/1/04, DMAP did not enroll or reimburse Independent Therapists for services. 9/1/2016
MetLife Auto & Home INTRODUCTION Decision Point Review and Pre-certification Plan Q & A At MetLife Auto & Home, we understand that when you purchase an automobile insurance policy, you are buying protection
Current Online Courses LSVT GLOBAL announces the launch of a new ONLINE educational course series: LSVT Global is expanding its ONLINE continuing education opportunities! In addition to our LSVT LOUD Training
CLAIM FORM REQUIREMENTS When billing for services, please pay attention to the following points: Submit claims on a current CMS 1500 or UB04 form. Please include the following information: 1. Patient s
March 2, 2015 Phyllis C. Borzi, Assistant Secretary Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue, NW Washington, DC 20210 RE: Summary of Benefits and Coverage
Understanding the Rehabilitation Process after No one can prepare a family for the trauma of experiencing brain injury. Following the injury the subsequent move from the hospital to various rehabilitation
NEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES PROCEDURE CODES & FEE SCHEDULE Table of Contents General Rules and Information... 3 Occupational Therapist, Physical Therapist and Speech Language
Colorado Medical Society Testimony to the Division of Workers Compensation Nov. 18, 2013 As Chairman of the Colorado Medical Society s Workers Compensation and Personal Injury Committee (WCPIC), I would
Page 1 of 14 SCOPE: Clinical Department IMPORTANT REMINDER This Clinical Policy has been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration
Status Active Medical and Behavioral Health Policy Section: Behavioral Health Policy Number: X-45 Effective Date: 01/22/2014 Blue Cross and Blue Shield of Minnesota medical policies do not imply that members
ConneCtiCut insurance DePARtMent Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral
Parent to Parent Pocket Pal Guide to Health Insurance Coordinated by Family Faculty Family-Centered Care May 2015 Welcome to Children s Specialized Hospital Dear Parents and Caregivers, In an effort to
DRIVER REHABILITATION OVERVIEW What is included in a Driving Evaluation? The purpose of the evaluation is to determine if the individual s medical condition, medications, functional limitations and/ or
CONNECTICUT INSURANCE DEPARTMENT Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral
2015 Level of Care Guidelines Psych & Neuropsych Testing Psychological and Neuropsychological Testing Introduction: The Psychological and Neuropsychological Testing Guidelines provide objective and evidencebased
Billing for the treatment of OSA with oral orthotics: Obstructive Sleep Apnea is a medical disease. All time and procedures involved in evaluating for or treating OSA is, therefore, generally covered only
HUMAN RESOURCES POLICY Fauquier County, Virginia Policy Title: Workers Compensation Effective Date: 05/17/04 36 Supersedes Policy: 09/04/90 I. PURPOSE It is the objective of the Board of Supervisors that
Short-term Disability Claim Form Instructions EPIC s Short Term Disability Claim Form has three sections you (the employee), your employer, and your attending physician(s) must each complete your corresponding
Nurses Knowledge and Self-Perceptions of Caring for Patients with TBI Tolu Oyesanya, MS, RN, PhD Candidate Roger Brown, PhD Lyn Turkstra, PhD, CCC-SLP 4/16/2015 Background TBI is a chronic disease process
SECTION 5 1 REFERRAL AND AUTHORIZATION PROCESS Primary Care Physician Referral Process 1 Referral from PCP to Participating Specialists 1 Referral from Participating Specialist to Participating Specialists
Unlisted Procedure Codes Frequently Asked Questions Use of an unlisted code is common when a physician performs a new procedure or utilizes new technology when no other CPT code adequately describes the
Parent to Parent pocket pal guide to health insurance Coordinated by Family Faculty Family-Centered Care January 2012 Children s Specialized Hospital 2010 Welcome to Children s Specialized Hospital Dear
Outline of Coverage Medicare Supplement 2016 Security Health Plan of Wisconsin, Inc. Medicare Supplement Outline of Coverage Medicare Supplement policy The Wisconsin Insurance Commissioner has set standards
Cassondra Quinn, MA CCC-SLP BRS-S Vancouver, Washington 98682 Phone: 503-725-3584 E-Mail: firstname.lastname@example.org Objective To use my academic, clinical, leadership and work experience in the field of speech pathology
The National Military Audiology and Speech Pathology Center at Walter Reed National Military Medical Center Bethesda: A New National Treasure In the NOV/DEC 2011 issue of Audiology Today, an article appeared
INTRODUCTION The Maryland Workers Compensation Commission (Commission) amended COMAR 14.09.03.01 (Guide of Medical and Surgical Fees) on February 12, 2004. AUTHORITY The Workers Compensation Act provides
Texas Workers Compensation Tips for Successful Medical Billing and Reimbursement Practices Presented by: Regina Schwartz Health Care Specialist Texas Dept of Insurance - Division of Workers Compensation
Applying to the Graduate Program Does your program focus on both clinic and research? It is a clinical program that provides research opportunities to work or volunteer in a lab. What s your average GRE,
Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company Insureds 2009 Contents How to contact us... 2 Our claims process...
California Workers Compensation Medical Provider Network Employee Notification & Guide In partnership with We are pleased to introduce the California workers compensation medical provider network (MPN)
NEW YORK STATE EXTERNAL APPEAL You have the right to appeal to the Department of Financial Services (DFS) when your insurer or HMO denies health care services as not medically necessary, experimental/investigational
Neurologic Rehabilitation Institute at Brookhaven Hospital Vision. Values. Commitment. Neurobehavioral Rehabilitation for individuals with difficult-to-manage behaviors following traumatic brain injury
Chiropractic Assistants Insurance Verification Training Guide What You Will Learn: How to Obtain Maximum Chiropractic Benefits Tools Needed to Verify Benefits Understanding Why You Are Verifying Understanding
3 O0100 O-1 Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure, such as IV medications or ventilators. Surgical procedures include routine pre-
Outline of Coverage Medicare Supplement 2015 Security Health Plan of Wisconsin, Inc. Medicare Supplement Outline of Coverage Medicare Supplement policy The Wisconsin Insurance Commissioner has set standards
I want a health care plan with all the options. PERSONAL BLUEPLANS SE These are my plans. Personal BluePlans SM SE PLAN FEATURES Personal Blue BluePlans SE let you build the plan that works for you. The
Prior Authorization for Therapy (OT, PT, ST) Updates Effective November 1, 2013 SHP_2013307B The following guidelines are effective November 1, 2013, and may be referenced in Superior HealthPlan s Policy
The Appeals Process For Medical Billing Steven M. Verno Professor, Medical Coding and Billing What is an Appeal? An appeal is a legal process where you are asking the insurance company to review it s adverse
CURRICULUM VITA Janet L. Hawley, MS, CCC-SLP Clinical Assistant Professor Speech-Language Pathologist Department of Speech, Language, & Hearing Sciences University of Arizona, Tucson, AZ 85721 Phone: 520-626-6073
Update on Brain Injury Rehabilitation 2015 Saturday, September 19, 2015 7:30 am to 4:00 pm This educational activity is intended for physiatrists, neurologists, internists, family practitioners, neurosurgeons,
Guidelines for Medical Necessity Determination for Occupational Therapy These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine
Developing a Stroke Aftercare Program Anna Maria Dunn, MD Associate Clinical Professor Rutgers Robert Wood Johnson Medical School, NJ Director of PM&R Services RWJUH JFK Johnson Rehabilitation Institute
Descriptions and Neuroplasticity Health care providers are facing greater time restrictions to render services to the individual with neurological dysfunction. However, the scientific community has recognized
California Provider Reference Manual Introduction and Overview of Medical Provider Networks (CA MPNs) Coventry/First Health has designed this manual for The Coventry/First Health Network providers participating
Benefit Coverage Outpatient cognitive rehabilitation is considered to be the most appropriate setting for members who have sustained a traumatic brain injury or an acute brain insult. Cognitive rehabilitation
HEALTH MANAGEMENT CUP recognizes the importance of promoting effective health management and preventive care for conditions that are relevant to our populations, thereby improving health care outcomes.
Zimmer Payer Coverage Approval Process Guide Market Access You ve Got Questions. We ve Got Answers. INSURANCE VERIFICATION PROCESS ELIGIBILITY AND BENEFITS VERIFICATION Understanding and verifying a patient
CLINICAL OUTCOME SCORES FOR THE FAMILY HOPE CENTER FOR 13.0 YEARS, COMPARED TO NATIONAL SAMPLE OF OUTPATIENT REHABILITATION FOR SIMILAR DIAGNOSES This document references data from a Report compiled and