room and board what's included how to stop denials

TRISLEY

We have a few insurance companies denying outliers based on supplies charges (rev) codes. How do we determine what rev codes / supplies should not be on the inpatient itemized bill. Any suggestions on how to appeal these?

RHirsch

ask your Compliance officer to read their issue of Report on Medicare Compliance that arrived yesterday. Nina Youngstrom wrote about it- 

• Payers Deny Separate Charges Using Their Own Policies, Pay Less Than Contracted Rates
  In their unbundling audits of hospital bills, some commercial payers are denying payment for items and services charged separately based on their policies, not Medicare language. The payers have been using the Medicare Provider Reimbursement Manual to support their position that hospitals can’t bill separately for routine and ancillary services provided during hospital stays, but there was pushback from hospitals, which contend the payers were misapplying CMS’s words. Now some payers are reverting to their own policies, a hospital official says…

TRISLEY

Thanks! I knew something is up, we are seeing a trend with several denials Aetna being a major one! We are fighting these but it's not easy.

mglynn431

Seeing a trend with this and Cigna.  Anyone else having this issue with Cigna?  If so, are you having success fighting them on not paying based on their policies?  Any information on how to fight these denials would be greatly appreciated.

dsoult

We have been fighting these for many months now. The payers are drafting policies to allow them to accuse us of unbundling our charges. We had success with Cigna on many of our claims because they were outliers and we had contract language that did not allow them to exclude charges from the outlier calculation separately from the approved and paid DRG portion of the claim. It was a lengthy battle for the contracting team and has taken months to collect back reimbursement owed. I believe it also helped that our contract contained language that policy changes that have an egregious impact on expected revenue per the agreed contract have to be sent, reviewed and approved by providers within a 60 day window prior to their implementing such a policy. We now have to set our sites on Kaiser Permanente as they have established a National Review process for outlier claims and are attempting to reduce payments based on these reviews.