Retaining Medicare Payments Requires MEC and Front-End Policies

Coverage policies from Medicare are increasing in number and complexity. Now is the time to implement preservice coverage analysis teams as part of your overall revenue integrity plan.

This article appears in the May/June 2018 issue of HealthLeaders magazine. 

CMS continues to develop national coverage determinations (NCD) and its Medicare Administrative Contractors (MAC) continue to develop local coverage determinations (LCD) for many high-dollar procedures.

These include treatments such as cardiac PET scans, bariatric surgery, hyperbaric oxygen therapy, pacemakers, joint replacements, cardiac defibrillators, and neurostimulators.

Coverage policies often require patients to fail months of lower-cost interventions before the more invasive and expensive procedures are covered. This is now the focus of Recovery Auditor scrutiny, as well as new MAC-initiated Targeted Probe and Educate (TPE) audits: Denials occur when provider medical records fail to prove coverage of these high-cost procedures. 

Hospitals are likely to suffer denials because they do not routinely validate coverage in advance of performing a procedure by obtaining required documentation of failed and conservative treatments from physicians. This supporting documentation is expected to be in the hospital’s medical record as well as the treating physician’s medical record. 

Denials are likely to become costly for hospitals once auditors discover a trend of vulnerability. This is a compelling reason for facilities to become proactive now and head off denials for future procedures.

Savvy hospital leaders will want to establish new policies by collaborating with the medical executive committee (MEC) and forming a preservice coverage analysis team to:

• Quantify past denials and whether they were successfully appealed
   
• Assess the most common procedures that require preservice coverage analysis based on the Medicare NCDs and/or LCDs 
   
• Identify the physicians who frequently perform those procedures
   
• Review a sampling of records for documentation gaps
   
• Meet with physicians, especially MEC leaders, to explore what processes will mitigate those gaps 
   
• Identify who will request records from clinicians, including other specialists and/or the primary care physician and possibly therapists 
   
• For hospitals using an integrated EMR, permit coverage specialists to access the treating physicians’ clinical records and put together the “picture” that supports coverage 
   
• Establish medical record policies 
   

Policies to prevent denials require executive leadership to work with stakeholders tactfully and thoughtfully. With MEC approval, policies can include a provision under which a high-cost procedure would be postponed until appropriate documentation is obtained.