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CMS Final Rule - coding student

Posted: Jan 30, 2013

This was published in the Federal Register last week, correct? I have a friend who is in a battle with an insurance company over a very sick child. They are always throwing up obstacles for coverage.

She told me that out-of-network treatment is covered at 50% of 200% of Medicare rates. So we are trying to uncover exactly what that rate is. Is the CMS Final Rule document what I am looking for to help her?

Is Coder here? Expert insight would be so appreciated

It depends on the treatment . . . - but you knew that

[ In Reply To ..]
You're trying to find what the Medicare rate would be for the service?

Rummage around on the Medicare website. www.cms.gov Try googling "cms Fee Schedule 2013," then choose the CMS link itself.

You need to use the rates that were in effect when the child had the treatment.

Let us know what you found.

Thank you - coding student

[ In Reply To ..]
The child has several diagnoses, including I believe 315.32. What is basically happening is that the child has a period of seizure activity and then loses language from the seizures. I don't know if there is a firm diagnosis yet, but it is similar to Landau Kleffner syndrome in that it is a rare seizure disorder (perhaps without a name yet) The child is very intelligent and there is no MR. There absolutely must be intensive therapies with the kind of speech delay that is being faced. Mom has managed to get child in for evaluations and consultation with a couple of world-class neurologists.

Mom is the hardest-working single mom that I know and yet she still manages to have her child in all of the therapies that the doctors are telling her are critical: speech, occupational therapy, physical therapy, and behavioral therapy (psychotherapy is the hardest therapy to get covered).

I want to help her not only gather information in order for her to fight denials of therapies (which were previously covered earlier in 2012), but to be prepared for this next year.

I found this: http://www.apta.org/PTinMotion/NewsNow/2012/11/2/FinalFeeSchedule/ and would absolutely love some help breaking it down. Mom is extremely intelligent and needs no hand-holding, just ammo. Puts me to shame!

There is not much protection coming from our state laws for these kids. The tactics that this insurance company has pulled on this family are even more despicable than usual. This child is beautiful and this family deserves any help you can throw this way. Thanks if you can help.

What is the problem you want to solve? - Coder

[ In Reply To ..]
From your first post, I thought you needed a source for the actual fee schedule itself. You said that the insurance company paid 50% of 200% of Medicare rates, so it seemed that you were trying to verify how much they would have reimbursed for, say, a particular claim. That's why I told you how to find the CMS Fee Schedule. Did you try that? Were you successful? Did it help in terms of giving you what you need?

The apta article is just an article. The link to the fee schedule is broken, so I'm not sure what you saw. I am not sure that breaking down the article is going to help, because there isn't anything in it that would be useful. But, I'm not sure what the problem is yet, either.

Insurance companies may be despicable, but if you are buying insurance from them, you have accepted their coverage rules. You accept that staying within network will cost you less. You accept that going out of network will cost you more. They don't pay for everything, even if your doctor thinks you need it. And a lot of times, it is the way the physician presents the case that determines if it gets paid or not.

So, there can be many reasons an insurer might deny payment. Medicare, for instance, has a lot of noncovered services. They may feel they are medically worthless or potentially harmful. They may expect to see "improvement" and deny coverage if no improvement can be expected, or if there aren't enough patients to tell if improvement can be expected. Insurers might deny particularly expensive, experimental services.

Insurers are not charitable institutions. Most of them are for-profit businesses. All patients are deserving, so arguments pointing toward that fall flat with them. You just have to deal with them in a focused, businesslike fashion.

First of all, you have to figure out what they cover. The policy tells you and their website tells you. The doctor's office should be able to tell you more about this.

You said they covered therapy earlier in 2012 but now do not? What changed?

Realize that the insurer has specific coverage rules and that you MUST accommodate the rules before they'll pay. They want to see exactly how those therapies will be beneficial. Is there medical evidence that they benefit patients WITH THAT DIAGNOSIS? Psychotherapy and speech therapy, for instance, might not be covered for a patient who has diagnosis 315.32, but might be for other diagnoses.

The diagnoses submitted by various physicians might be differing enough to indicate that the problem is not severe or that it isn't known what the problem is. Or, if you know that therapies are covered, it might be that therapists are submitting incorrect information, leading to denials.

It might just be the practice of this insurer to deny most claims up front, only paying them after the doctor or patient exhibit significant effort to get paid.

As aggravated as you might be with this insurer, a "working with them" mindset helps more than a "fighting against them." Fighting them is very hard, but you can often get some success from objective, calm, sincere efforts.

Getting coverage "in general" won't work. You have to do it for each therapy or service.

Find out from the insurer what they cover and under what circumstances. If the services ARE covered, then they should be paid. Figure out why payment was denied. The insurer will tell you, but it might be in their coded lingo and hard to figure out. Is it the diagnosis? The procedure code? Or did the care provider fail to file the claim correctly? Did they use the wrong codes for it? Did they fail to submit the documentation that was necessary? Were the therapies ordered correctly? Did the insurer receive documentation of that?

If the service is NOT covered, things are much more difficult. You then have to demonstrate that services SHOULD be covered and why. If they were paid last year, but now are not being paid, the actual coverage might not be the problem. We'll hope that isn't what it is.

Keep in mind that if Medicare does not cover something, that something will not be on the fee schedule. It isn't a verbal description of the something, either, but the CPT code number. That code has to appear on the fee schedule. Think about it . . . if code is not there with a payment rate listed, how can you calculate the payment? If a care provider called it code abcdef last month, but now calls it abchij, and abchij isn't covered . . . Or, if abchij and abcdef are only covered for particular diagnoses and the diagosis matches abcdef but not abchij . . .

Find out what they cover. Compare the paid claims and denials to what they cover. That tells you what the problem is.

Another tactic might be more productive, especially if the insurer simply will not cover the services. If this child is that ill and will require that kind of intensive treatment, see if Medicaid would be a better option for the family.

The Wikipedia article on this condition notes that Boston Children's has a program for this. If the family is in a program like that, they can help get it covered. After you get all your ducks in row, you might contact them for advice.

That article listed some references. You can find more, most likely, using a Medline or PubMed search (google it). If scholarly articles support the use of those therapies, then you can use them to justify coverage, but if they do not, the insurer will use them to de-support them.

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