Insurance Coverage for Bariatric Surgery Surgeon s Guide to the Appeals Process

Transcription

1 Insurance Coverage for Bariatric Surgery Surgeon s Guide to the Appeals Process

2 Insurance Coverage for Bariatric Surgery Surgeon s Guide to the Appeals Process Provided as a Service of Covidien Introduction: Your involvement is...02 Overview: What s behind the appeals process...03 Participants: Each player has a unique role...04 Your role as surgeon Your patient s role The role of the employer Levels of Appeal: How the process works Request for prior authorization st level appeal Strategies for 1st level appeals Outcomes of 1st level appeals 2nd level appeal Strategies for 2nd level appeals Outcomes of 2nd level appeals 3rd level appeal Strategies for 3rd level appeals Outcomes of 3rd level appeals Communication: Guidelines for a successful appeal Appendix Sample physician appeal letter - Outline of Content For quick reference: Appeals process summary Contacts during the appeals process: Sample log form Glossary of terms INTRODUCTION Your involvement is essential As you are probably aware, getting patients approved for Bariatric Surgery procedures can be a challenging task. Establishing a smooth and productive reimbursement process with your payers can consume much of your time and energy. The criteria for patient approval varies from carrier to carrier, but in general insurance company payments are determined by the number of procedures performed and the contracted fees negotiated with the surgeon and hospital and the Current Procedural Terminology (CPT) codes billed. As is often the case, the initial request for insurance coverage for the procedure may be denied. Typically denial falls into two categories: 1) Either the patients are having difficulty meeting the insurer s pre-surgical conditions or 2) the insurer is still of the mindset that bariatric surgery is too risky or investigational even after FDA approval, over 20 years of experience and 50,000+ completed cases worldwide. As a physician with your patient s best interests in mind, you have the authority, knowledge, and medical experience necessary to initiate an effective appeal and reverse a payer s decision. This guide is intended to provide general information and tools that can assist you to do just that. Leading an appeal will require greater involvement on your part, but its well worth the effort. A successful appeal based on the specific medical needs of your patient can make a real difference in his or her overall health and everyday life. Disclaimer and Exclusion of Liability [2]

3 Overview PARTICIPANTS What s behind the appeals process? Most healthcare plans take a cautious approach to new technologies or high risk or investigational surgery. A payer may choose to deny requests for insurance coverage until the healthcare plan has had an opportunity to conduct its own formal review known as a surgical or new technology assessment. This is a formal review of the procedure, its indications, exclusions and outcomes. An assessment can be conducted internally (within the payer s organization) or externally (by an independent review firm). Typically, a panel of experts is identified to review published literature, clinical trial results, costs, appropriate patient populations, and health outcomes associated with the requested procedure as well as general information about the disease indication. Members of the panel generally review the materials independently and then form a collective opinion. Though not binding, this opinion heavily influences a payer s decision to provide coverage for such procedures. If the assessment confirms that the Bariatric surgical procedure is a safe and effective treatment option for plan members, the process of obtaining insurance coverage for patients is relatively simple and straightforward similar to that required for other payer-approved treatments and procedures. Until a procedure for the patient is payer-approved, however, you and your patient may need to appeal for insurance coverage by providing additional information and arguments in support of the surgical procedure. The appeals process varies from plan to plan but may involve as many as three parties and three levels of appeal. As you initiate an appeal, keep in mind that any insured patient who is denied coverage is entitled to have his or her case reviewed. Most payers are regulated by state and/or federal laws designed to ensure that patients are treated fairly and equitably. These laws require healthcare plans to act honestly and in good faith in fulfilling their contractual obligations to their members. Most payers make every effort to do more than merely fulfill their legal obligations. They try to reasonably assess the needs of the individuals covered under their plans. Three parties are frequently involved in appealing a payer s decision to deny insurance coverage: you, your patient, and your patient s employer. Occasionally a patient advocate or advocacy group may also be helpful in championing the patient s case before the healthcare plan. Your role as surgeon Your knowledge and experience with the patient makes you the medical expert in the appeals process. You understand the unique medical needs of your patient; you are also in the best position to present a convincing case in favor of the recommended surgery and overturn a denial of coverage. Furthermore, through your leadership and partnership with the patient, you can help empower him or her to participate in the appeals process. You can also identify situations when it makes sense for the patient s employer or a patient advocate or advocacy group to get involved. Your patient s role As the individual with the most to gain or lose from the healthcare plan s decision, your patient should be encouraged to take an active role in the appeals process. There are a number of ways that your patient can become involved and influence the outcome of a payer s decision. These include: Obtaining the benefits booklet or other document containing the healthcare plan s guidelines and policies on the appeals process Personally contacting the healthcare plan to discuss a decision over the phone Writing a thoughtful appeal letter, one which outlines the impact of their obesity on their health and daily life and argues against the insurer s reasons for denial Asking for advice from the employer who sponsors the healthcare plan the role of the employer Most patients acquire healthcare insurance coverage through regular employment. The employer is considered the plan holder; the employee, the plan subscriber. Because employers represent large groups of members in the healthcare plan and can opt to switch plans if members are dissatisfied, employers can have a great deal of clout in the appeals process. Patients are likely to find that talking with the employer about a payer s decision and involving the Human Resources department in an appeal may prove useful in reversing a denial of coverage. Together you, your patient, and your patient s employer can be a powerful team in appealing a payer s decision to deny coverage. [3] [4]

4 APPEALS Levels of Appeal: How the process works. Request for prior authorization Generally, before a patient undergoes elective surgery, most healthcare plans require prior authorization of the procedure. For most procedures, your office staff requests prior authorization by phone. In the case of Bariatric surgery, however, you should have your staff submit a letter requesting prior authorization, also known as a letter of medical necessity. A letter of medical necessity should include the following information: Specific details of the patient s case history, duration and degree of illness/injury, and a summary of your and prior physicians clinical experience with the patient, including previous failed treatments A description of how the patient s condition affects his or her ability to work, conduct daily living functions, participate in activities designed to improve his or her clinical condition (i.e. exercise, physical therapy, weight loss programs), and ability to sleep are all good examples to include. A summary of the clinical evidence (i.e., published literature) that supports the safety and efficacy of Bariatric and associated surgical procedures as it relates to the patient s medical condition In addition, it is helpful to include documentation regarding the billing codes and a bibliography of relevant peer-reviewed published literature on the specific procedure. After you submit the letter of medical necessity, you or your office staff should receive the healthcare plan s written response, your patient may receive a copy of the response as well. If the healthcare plan approves your request for prior authorization, no further action is required. 1st level appeal If you or your patient receives a communication indicating a denial of coverage, you should consider initiating a formal appeal. Typically, the communication is in writing and originates from the designated plan s representative who has reviewed your request. The letter denying coverage should: Clearly state the reason(s) for the decision Refer to the healthcare plan provisions upon which the denial of coverage is based Indicate additional written material or information that can be submitted that might change the healthcare plan s decision Discuss the procedure for requesting an appeal of the decision If the denial letter does not include the information listed above, immediately submit a written request to the healthcare plan representative for this information. If you receive a denial letter with appropriate supporting information, it is important to take time to gain a thorough understanding of the payer s reason(s) for denial of coverage. Try to determine whether the denial involves: A medical issue (refusal to authorize surgery) An administrative issue (refusal of benefit due to lack of coverage) If you or the patient have questions or need further clarification, don t hesitate to contact the designated plan representative by phone to discuss the case and get the answers you need. Once you understand the reasons for denial of coverage, you and your patient can initiate an appeal formulated according to the instructions in the benefits booklet or those received directly from the healthcare plan. Keep in mind that, throughout the appeals process, reviews of your requests for coverage must be conducted according to regulations that govern the healthcare plan, which is overseen by state officials and, ultimately, the state Department of Insurance (DOI). During the appeals process, it is important that both you and your patient keep accurate records of all interactions with the healthcare plan and monitor the timeliness of the plan s response. (See sample form for recording this information enclosed.) Strategies for 1st level appeals Even though Bariatric Surgery is not new, it may still be considered a high risk procedure for some insurers. This may be due to actual safety concerns for their members, concern for their own return on investment or probably in most cases a little of both. There is still a lot of misinformation and prejudice surrounding obesity and who should pay for treatment. It is very important to continue the education process by providing information such as outcome data and the short and long term advantages associated with the latest bariatric procedures. Another common reason for initial denial of insurance coverage is the payer s general medical policy, which specifies that the treatment you request is not reimbursable? Typically, healthcare plans rely heavily on medical policy and apply it across the board to all members, without regard for individual circumstances. In this case, your strategy for a 1st appeal should be to request individual consideration. A request for individual consideration should be directed to the designated healthcare plan representative and should ask that the plan reconsider its decision in light of your patient s specific medical needs, rather than overall policy. Ideally, the request should include a letter from you with appropriate clinical documentation explaining your patient s medical needs, accompanied by a letter from your patient that explains why the surgery is necessary from his or her perspective. (See outline of sample letter.) If the plan responds with a favorable decision to your request for individual consideration, the decision will apply only to the patient in question not to all members of the plan. [5] [6]

5 Outcomes of 1st level appeals When you submit the 1st appeal or request for individual consideration, be aware that most healthcare plans follow a definite timeframe for appeals. If you or your patient fail to meet the timeline, the patient may lose the right to appeal. Generally, payers make every effort to adhere to their published timeframes. Nonetheless, it is good to keep track of the expected response date to the appeal. Regardless of when you receive the decision, the insurer should provide it in writing. If the plan issues a favorable decision, no further action is required on your part or on the patient s part prior to surgery. However, if your patient is denied insurance coverage again, most healthcare plans offer the opportunity for a 2nd level appeal. 2nd level appeal If a healthcare plan responds to the 1st appeal by denying coverage, the written communication you receive should contain the following information: the reason(s) for denial, documentation supporting the decision to deny coverage, an outline of the next steps in the appeals process, and the appropriate timeframe for the appeal. Again, you and your patient should carefully review this information, clarify any issues with the payer, and then strategize about how to proceed with the 2nd level appeal. Strategies for 2nd level appeals One common strategy for a 2nd level appeal is to write and request a full and fair review of your patient s case. This means: The case should be reviewed on its own individual merits and the patient s specific circumstances The review should be conducted by an independent physician who was not involved in the original decision to deny coverage The review should be done school to school; in other words, the physician reviewer, who: Works in the same specialty as the patient s surgeon, i.e., Bariatric and/or general surgery Is familiar with and perform bariatric, digestive or abdominal procedures -, laparoscopic and open Routinely treats patients with Morbid Obesity In addition, a full and fair review should allow direct discussion between you and the physician reviewer so that you can present specific facts to the reviewer about your patient s case as well as your rationale for treatment. Keep in mind, requesting a full and fair review is a good strategy; however, the healthcare plan is not obliged to comply with this request. Another common strategy for a 2nd level appeal is to involve the patient s employer and/or a patient advocate or advocacy group. A patient advocate or advocacy group helps bridge the gap between the patient and the payer. They work on behalf of the Patient advocacy groups that can assist with denials of coverage for Bariatric treatment and surgical procedures, include those associated with Obesity, Morbid Obesity and Metabolic Disorders. Outcomes of 2nd level appeals An insurer will usually render a decision on a 2nd level appeal within the timeframe specified in previous written communication or the benefits booklet. The insurer should provide written notification if the review takes longer than expected and should indicate the reason(s) for the delay as well as the anticipated date for the final decision. Throughout the appeals process, you and your patient can help prompt a faster response by requesting an expedited review and/or following up frequently with the designated representative of the healthcare plan. However, since Bariatric surgery is an elective procedure, the payer is not obligated to conduct an expedited review. In most instances, a denial of coverage for Bariatric Surgery after a 2nd level appeal will be based on the healthcare plan s opinion that the procedure is still investigational or that your documentation of the patient s efforts to meet the carrier s presurgical requirements has not been adequate. (ex. 6 months on a medically documented weight loss program) In other words, the plan believes that the amount or caliber of long-term data published in U.S. medical journals is insufficient to document the safety and efficacy of treatment or they are standing firm on their interpretation of the pre-surgical requirements they have outlined in their policies. 3rd level appeal Some healthcare plans permit a 3rd level appeal. Third level appeals can occur as much as 3 months after the initial request for prior authorization. Therefore, if any new clinical information is available on the surgical procedures or the patient has accumulated more documentation pertaining to their pre-surgical requirement this material should be included in the appeal. Strategies for 3rd level appeals At this stage of the appeals process, your patient should consider contacting the state Department of Insurance (DOI). Contact information for the state DOI can be found in the yellow pages of your phone directory under state government agencies. You can also source this information from the internet on the state s homepage. In addition, if your state has a local Office of the Ombudsman, your patient should get in touch with the office. The Ombudsman can provide additional information about avenues of appeal available to your patient and may sometimes act as a patient advocate. Typically, if after the 3rd level appeal, the healthcare plan continues to deny insurance coverage, you and your patient have exhausted all channels in the appeals process. If your patient wishes to further pursue insurance coverage, he or she can consider legal action. patient, championing the patient s cause with the healthcare plan. [7] [8]

6 COMMUNICATION Guidelines for a successful appeal In your ongoing communication with the healthcare plan, keep in mind that the appeal is about what is in the best interests of your patient. As the treating physician, your opinion is crucial in terms of determining which treatment is medically necessary for your patient. Here are some guidelines to keep in mind as you go through the appeal process for Bariatric Surgery: In all communication, written or verbal, be sure to identify and refer to the patient by name to humanize the process Clearly state your reasons for disputing the payer s decision Specifically address each point that the payer has used to deny your request for coverage Always make your appeal in your own words Be sure to refer to the patient s medical record and indicate the length of time that the patient has been in your or another physician s care regarding their obesity. Discuss all resulting co-morbidities, their severity and potential long term effects. Include the patient s medical history, physical exams, clinical evaluations, and verbal complaints Clearly demonstrate that the patient has failed to respond to all conservative measures with any consistency or any notable clinical improvement. Point out that, regardless of the plan s decision on coverage, your patient requires a therapeutic intervention; in this case, surgery Explain that the patient s condition is serious, that long-term success rates are best with surgery, and that the patient is committed to making this lifestyle change. State that your outcome data is positive and clinically effective. (Include your outcome data vs. national statistics if available) Cite any other specific clinical data that has led you to this decision and state, that for this particular patient Bariatric surgery is the treatment of choice Whenever possible, be sure to quote peer-reviewed published literature and statements from the patient s own benefits booklet to demonstrate how Bariatric Surgery meets the health plan s definition of a covered benefit. (NOTE: The bibliography in the Appendix lists published articles on obesity, metabolic issues, and Bariatric surgical procedures that are available for citation) Emphasize that, as the treating physician, your medical opinion regarding what is in the best interest of your patient should carry more weight than a chart review conducted by a well-meaning person who has limited knowledge of the patient and may not be familiar with the Bariatric surgical procedures. Point out that your treatment recommendations are based on your medical opinion as a highly qualified Bariatric surgeon, who has been in practice for a number of years (be sure to specify the number.) Mention that you have undergone training specifically focused on Bariatric surgery, including, fellowships, hands-on preceptorships, and lectures regarding surgical technique Whenever necessary, be sure to request an opportunity to speak directly with the physician reviewer assigned to the case [9] [10]

7 Appendix Sample physician appeal letter This outline suggests one method of organizing your appeal letter. Please remember that you should tell the patient s story and present your medical conclusions in your own words. [Date] [Individual Name, MD] [Insurance Company Name] [Insurance Address] [City, State, Zip] Re: Request for Reconsideration of a Denial of Coverage [Name of Patient] [Subscriber ID Number] Dear [Name of representative from healthcare plan]: Paragraph 1 State the name of the patient covered under the insurer s program State the date of the denial State that the procedure requested is the [Insert Type] Bariatric surgical procedure Paragraph 2 State the length of time that you have had [name of patient] in your care State that [name of patient] has a diagnosis consistent with the indications for Morbidly Obesity. Explain that all other previous non-surgical weight loss options for [name of patient] have failed Paragraph 3 State that, after discussion with [name of patient], it is your opinion that the most appropriate treatment option is the [Insert Type] Bariatric surgical procedure. Emphasize that this recommendation is not made lightly, given the nature of the planned surgery Paragraph 4 Point out that the Bariatric surgical procedure has extensive clinical experience behind it, noting: Large number of patients in the United States who have already received it Positive reported outcome data, low complication rates and high patient satisfaction Refer to any personal experience you have had performing this surgery, and to your Bariatric surgical training Paragraph 5 State that Medicare and a growing number of insurance companies are now covering Bariatric surgery. Most importantly, emphasize that [name of patient] meets the BMI criteria set by the National Institute of Health and that surgery is now being considered as an appropriate option for such patients by the American Academy of Family Physicians Paragraph 6 Mention the goals of surgery with the Bariatric Surgery: to achieve weight loss, improve other co-morbidities and the patient s overall quality of life. Restate your position that [name of patient] is an excellent candidate for this surgery and you support his or her request for an appeal of denial of coverage Paragraph 7 State that you believe that this case should be reviewed based on individual patient consideration and not on medical policy Request a full and fair, school-to-school review with the opportunity to discuss the case directly with the reviewer Paragraph 8 Conclude by stating that you trust that [name of payer] will grant an approval of this surgery so that together you can provide the best possible care to [name of patient] Add that, given the duration of [name of patient] s condition and his or her present quality of life you look forward to a timely reply Sincerely, [Physician name and signature] Enclosures: Copy of letter of appeal from [name of patient] Supporting clinical literature Medical records of [name of patient] [11] [12]

8 Appendix Appendix Quick reference - Appeals process summary Request for pre-authorization Write a letter to your patient s healthcare plan requesting insurance coverage for Bariatric Surgery. If the plan approves, no further action is required 1st level appeal If the insurer does not approve your pre-authorization request, both you and your patient should write appeal letters to the insurer. (See previous section s suggestions about the content of your letter) Potential strategies: Provide more details about the surgical benefits and clinical documentation to dispute any objections Submit a request for individual consideration, based on the merits of the case and the needs of your particular patient Contact the insurer s designated representative by phone to ask questions or clarify any issues If the plan approves, no further action is required 2nd level appeal If the first appeal is denied, you and the patient should write another letter to the insurer Potential strategies: Request a full and fair review by a physician not previously involved in the case Ask that the review be conducted school to school Request that the physician reviewer be knowledgeable about Bariatric Surgery Request an opportunity to discuss the case with the physician reviewer Work closely with the patient to get the patient s employer involved in the appeal Alternatively, involve a patient advocate or advocacy group in the appeal If the plan approves, no further action is required 3rd level appeal If the insurer continues to deny coverage, you and your patient will need to write a final letter to the insurer and appropriate state agencies, such as the DOI or Office of the Ombudsman Potential strategies: Initiate patient advocacy by contacting all appropriate local and state agencies Contact the patient s employer to find out whether the employer is willing to contact the payer and act as a patient advocate. (NOTE: You can offer to provide return-to-work and job productivity data to help increase the employer s willingness to participate in the appeal) Post 3rd level appeal Typically, if the 3rd level appeal proves unsuccessful, you and your patient have exhausted all steps in the appeals process. The patient can consider legal action. Contacts During the Appeals Process: sample log form Set Up Grid or Excel Spreadsheet for optimal tracking of contacts and progress. Your Name Type of Insurance Member/Group Number Appeals Case Numnber Type of Contact Request for Prior Authorization 1st Level Appeal 2nd Level Appeal 3rd Level Appeal Employer: Advocate / advocacy Group: Office of the Ombudsman: Other Call Date & Time Person Contacted: Name/Title Dept/Phone Issues Discussed & Outcomes Next Steps Date for Follow-up [13] [14]

9 Appendix: Glossary of terms Appeals process The process by which a patient seeks to overcome a healthcare plan s denial of insurance coverage for a medical technology or procedure and receive reimbursement for surgery. Typically, the process involves up to 3 levels of appeal and up to 3 parties. DOI Department of Insurance. As an organization within the federal government, this department oversees the functions of all healthcare plans and is the ultimate authority in the appeals process. Full and fair review A review of an appeal that is conducted by a physician who has not been involved in a payer s original decision to deny insurance coverage. During this type of review, the patient s case is examined primarily on its individual merits and the patient s individual circumstances. IDE Investigational device exemption. The exemption from FDA that allows companies to ship investigational products to hospitals to conduct clinical studies of the product. The clinical studies will be reviewed by FDA to determine whether the device can be marketed in the US. Letter of medical necessity Written by the treating physician, this letter attempts to prove that the requested procedure or technology is necessary for a specific patient. Generally, the letter includes details and a history of the patient s case, a description of how the patient s condition affects his or her activities of daily living, and published literature that supports the safety and efficacy of a new technology or procedure. Medical policy Reimbursement guidelines and procedures that govern all members of a healthcare plan. Office of the Ombudsman A government office available in certain states only. The Ombudsman can assist in the appeals process by suggesting additional avenues for appeal and can also act as a patient advocate. Patient advocate An advocate or advocacy group champions the patient s case before the healthcare plan and helps bridge the gap between the patient and the payer. Patient advocates can often be very effective in helping to overturn a denial of insurance coverage. Patient benefits booklet Distributed by the healthcare plan to its members, the booklet usually contains detailed information regarding the plan s policies, benefits, and procedures for appealing denial of insurance coverage. Prior authorization A request for prior authorization is required by most healthcare plans if a patient wishes to obtain insurance coverage for an elective surgery. The process involves either verbal or written communication between physician or his or her staff and the payer regarding the type of procedure to be performed, the rationale for surgery, the patient s history, and clinical documentation regarding the success of the surgery. In the case of Bariatric Surgery, a letter requesting prior authorization must be supplied to the insurer. School-to-school / Peer-to-Peer review In this type of review, an insurer hires a physician as a consultant to evaluate an appeal. The physician generally works in the same specialty as the treating physician, performs identical types of procedures, and has experience treating other patients with the same condition. Therefore, he or she is especially qualified to review the case. [15] [16]

10 DISCLAIMER AND EXCLUSION OF LIABILITY The information contained in this booklet is intended to be a general guideline only. Insurance requirements and procedures vary among insurers, whether public or private, and are subject to change. Covidien expressly disclaims any express or implied warranty that the information contained in this booklet is current, accurate or complete, or that adherence to the suggestions or other guidance contained in this booklet will result in a favorable coverage or reimbursement decision or comply with all reimbursement procedures or requirements of any particular health care reimbursement program or policy. In addition, Covidien expressly disclaims any express or implied warranty of merchantability, fitness of a particular purpose and non-infringement of intellectual property with respect to this booklet and the information it contains. Covidien does not assume liability, and under no circumstances shall Covidien be liable, for any damages, cost or expense arising out of the use of the information contained in this booklet. [17] [18]

11 COVIDIEN, COVIDIEN with Logo and marked brands are trademarks of Covidien AG or its affiliate Covidien AG or its affiliate. All rights reserved SS 1M 6.08 CBK00060M 150 Glover Avenue Norwalk, CT [t]