what’s so interesting about medical necessity? interesting case presentation saint francis...

What’s So Interesting About

Medical Necessity?

Interesting Case Presentation Saint Francis Hospital & Medical Center

Dept. of PediatricsOctober 30, 2009

Jay E. Sicklick, Esq.Center for Children’s Advocacy

Hartford, Connecticut

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Interesting Case – The Parameters

Patient is a Medicaid Recipient Medicaid = HUSKY= Title XIX

Patient is birth through 20 Patient’s pediatric/family

medicine/psychiatric, etc. clinician has requested a medically related treatment, care or service o/b/o patient

This request is subject to some sort of review by the insurance carrier/primary payer

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What is Medical Necessity?

AN Interesting Case

AN Interesting Case 7 y.o. girl - seen in primary care since birth. Primary diagnosis is Pervasive Developmental

Disorder (PDD). Autistic tendencies & very low IQ Diet is extremely limited – like sweet and salty

foods only (chips, etc.) PCP believes that nutrition is compromised Would like to prescribe an OTC nutritional

supplement (Ensure/Pediasure) R/Q made to MCO R/Q “denied” as not “medically necessary” It this “medically necessary” care and treatment?

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ANOTHER Interesting Case

ANOTHER Interesting Case

14 y.o. boy with dx of spina bifida Mobility in h/h is at issue Lives alone with mother Treating provider and PT believe “track”

system in house will provide better mobility in h/h

Request made to MCO as a DME Request DENIED? Is this “medically necessary?”

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Medical Necessity:The Threshold Questions

What is Medical Necessity (“MN”)? Is there a standard for defining MN? Are pediatric patients evaluated under the

same MN standard as adults? What is the definition of MN? Who/What is the gate keeper for MN? Is there anything I (the pediatric provider)

can do to ensure my medical judgment is deferred to in the “ask” for MN care?

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Medical Necessity:The Threshold Questions

If my “ask” is denied, what is my recourse for the patient?

Can legal assistance be helpful in the event the request is denied?

What is the “appeal” process? Are appeals usually successful? What can I do next time to ensure that the

original request is granted (if anything)?

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Medicaid: A Refresher

Medicaid: A Refresher Title XIX of the Social Security Act for =

Medical Assistance for the Poor Not Medicare - Title XVIII = Federal Health

Insurance Linked to Social Security Categorical Eligibility = Elderly, Blind,

Disabled, Pregnant women & Children De-linked from Cash Assistance &

Resources

Medicaid: A Refresher Vendor Payment

System - hospitals, nursing homes, pharmacies, doctors & dentists are reimbursed

Participation by provider voluntary

No cost sharing allowed - theoretically

How Medicaid Works:The Federal-State Partnership

How the Partnership Works:The Federal Side

Federal oversight through central agency = CMS

Promulgates regulations, guidelines & statutes

Issues waivers Reimburses from 50%

to 83% of state costs Legal principles = due

process

The Partnership: State Administration

State Agency - Designated in Conn. As DSS

The “Medicaid Plan” Must conform to

federal law and apply statewide

Medicaid Advisory Committee req’d (MMCC)

Managed Care: Medicaid’s Panacea

State’s may contract with managed care entities to provide services (per CMS waiver): PCCM – case management w/monthly fee by

M.D.’s, group practices, APRN’s, PA’s or nurse midwives

MCO’s – contracts w/HMO’s, etc. w/capitation payment per enrollee

State’s can r/q most individuals to enroll in managed care programs (need choice of at least 2 entities

Managed Care Players

The Return to Managed Care:Connecticut’s Grand

Experiment Children eligible for MA coverage must

elect MCO for “coverage” or may be part of a PCCM practice through DSS

MCO’s contract with State DSS Three MCO’s presently provide managed

care coverage for state’s HUSKY population: CHN AETNA Better Health AmeriChoice by United Healthcare

The Return to Managed Care:Connecticut’s Grand

Experiment PCCM available in:

Waterbury Windham

Hartford & New Haven expansion planned

MCO’s are at-risk. Approve or deny coverage for services

pursuant to DSS contract and state and federal regulations.

Fee for service (“Straight Title XIX”) still available in limited circumstances …

HUSKY Basics Connecticut’s

Children’s Medicaid Plan (“A”)

Birth up to 19 y.o. Income based (family

or self) – no resource test

98% Insured through MCO’s (BCFP, Health Net & CHN)

Straight Title XIX available

HUSKY Basics (cont)

No co-pays or premiums

“Medically necessary services” must be covered

EPSDT requires periodic screening, diagnosis & treatment

Rights of appeal & legal challenges inviolate

Who is NOT Eligible for HUSKY?

Children in U.S. on vicarious visas (e.g. parent work visas)

Undocumented (illegal) Immigrant children

Families income > 185% FPL

Immigrants and HUSKY Eligibility based on residency status:

Lawful Permanent Resident (LPR) Refugees and asylees Certain battered spouses & children

Application Process Same for legal immigrants as they are for US

Citizens CT Resident Income guideline (185% child, 150% parent

Will NOT be considered Public Charge

Changes in the AIR

Medical Necessity:Defining The Playing Field

Two Part Analysis of Medical Necessity:

Definition of MN in State Regulations

Definition of MN in EPSDT

Medical Necessity – State Regulations

Previous Definitions (before 10/1/09): "Medical Necessity or Medically Necessary" means

health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or prevent a medical condition from occurring.

"Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally‑effective alternative treatments or diagnostic modalities.

Medical Necessity – State Regulations

Language change – October 2009 Definition is:“Medically necessary services” means those health services

required to prevent, identify, diagnose, treat, rehabilitate or ameliorate a health problem or its effects, or to maintain health and functioning, provided such services are:1. consistent with generally accepted standards of medical

practice2. clinically appropriate in terms of type, frequency, timing, site

and duration;3. demonstrated through scientific evidence to be safe and

effective and the least costly among similarly effective alternatives, where adequate scientific evidence exists;

4. efficient in regard to the avoidance of waste and refraining from provision of services that, on the basis of the best available scientific evidence, are not likely to produce benefit.

Tracking the Changes PRE-CHANGE:

to assist an individual in attaining or maintaining an optimal level of health

POST CHANGE: to prevent, identify, diagnose,

treat, rehabilitate or ameliorate a health problem or its effects, or to maintain health and functioning

demonstrated through scientific evidence to be safe and effective and the least costly among similarly effective alternatives, where adequate scientific evidence exists;

efficient in regard to the avoidance of waste and refraining from provision of services that, on the basis of the best available scientific evidence, are not likely to produce benefit.

What Does It All Mean? MCO’s & DSS (fee for service cases) review

each request pursuant to the MN standards

Provide a written response to the patient if denied

Allow opportunity for an internal review and, if necessary, an impartial hearing pursuant to Due Process requirements

Requests must also be reviewed pursuant to federal EPSDT standard

EPSDTThe problem is to discover, as early as possible, the

ills that handicap our children. There must be continuing follow-up treatment so that handicaps do not go untreated. . . . We must enlarge our efforts to give proper eye care to a needy child. We must provide health to strengthen a poor youngster’s limb before he becomes permanently disabled. We must stop tuberculosis in its first stages before it causes serious harm.

- - President Lyndon B. Johnson Introducing the EPSDT Legislation 90th Cong., 1st Sess. (1967).

What is EPSDT, or; Why does it make better

pediatricians?

Early periodic screening, diagnosis, and treatment

Federal mandates for screening at periodic intervals

Medical, vision, hearing & dental, immunizations, lab tests (including PB), health education

Mandate for coverage of treatment to “correct or ameliorate” physical/mental illness during the periodic or interperiodic screens

Outreach & transportation

Medical Necessity Under Federal Law

Medical necessity Definition requires coverage of “necessary health care, diagnostic services,

treatment, and other measures . . . to correct or ameliorate defects and physical and mental illnesses and conditions[.]

42 U.S.C. § 1396d(r)(5)

Applies to physical and behavioral health

EPSDT Scope of Benefits42 U.S.C. §§ 1396d(r)(5),

1396d(a) Mandatory services:

Inpatient hospital services Outpatient hospital services Rural health clinic services Federally-qualified health center services Laboratory and X-ray services Nursing facility services for adults EPSDT services Physician services Family planning services and supplies Physician services Medical and surgical services furnished by a dentist (with

limitation) Nurse-midwife services Pediatric nurse practitioner or family nurse practitioner

services Home health services for persons eligible to receive nursing

facility services

EPSDT Scope of Benefits – cont.

Optional services (for adults, mandatory under EPSDT when necessary to correct or ameliorate an illness or condition):

Home health care services (includes nursing services, home health aides, medical supplies and equipment, physical therapy, occupation therapy, speech pathology, audiology services) Private duty nursing services Clinic services Dental services Physical therapy and related services Prescribed drugs Dentures Prosthetic devices Eyeglasses Other diagnostic, screening, preventive, and rehabilitative services, including any medical or

remedial services recommended for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level

Intermediate care facility for the mentally retarded services Inpatient psychiatric hospital services for individuals under age 21 Hospice care Case-management services TB-related services Respiratory care services Personal care services Primary care case management services Any other medical care, and any other type of remedial care recognize under state law,

specified by the Secretary (of DHHS)

So – What Does it All Mean?

Advocacy Strategies:Making the Case for Medical

Necessity Three part strategy:

Anticipate

Advocate

Appeal

Reminder – AN Interesting Case 7 y.o. girl - seen in primary care

since birth. Primary diagnosis is Pervasive

Developmental Disorder (PDD). Autistic tendencies & very low IQ Diet is extremely limited – like

sweet and salty foods only (chips, etc.)

PCP believes that nutrition is compromised

Would like to prescribe an OTC nutritional supplement (Ensure/Pediasure)

R/Q made to MCO R/Q “denied” as not “medically

necessary” It this “medically necessary” care

and treatment?

ANTICIPATE

MN Advocacy – Anticipate What Do you Need to do to make sure your

patient receives the care/treatment requested? What are the facts that make this patient’s case

compelling? Previous treatments tried, results produced, etc. Think of alternatives and how you can address those

(HMO response) Document successes in other patients Think about how this case might be unique/special

MN Advocacy – Advocate Write a Letter Advocating for Your Request

Explain who you are State the language of the law … i.e. why this

service/treatment is medically necessary “Pat Patient needs this nutritional supplement

because I expect that it will enable her to maintain health an functioning, it is consistent with generally accepted standards of practice, and it is clinically appropriate in terms of type, frequency, etc …

Include specifics & details relating to the patient’s illness or disability

MN Advocacy – Advocate Write a Letter Advocating for Your Request

The details: Explain how the treatment will prevent an illness or

disability, or Explain how it will ameliorate a health problem or its

affects, or Explain how it will maintain health or functioning

(maintain functional capacity) Conclude by indicating the medical

consequences which you believe will result if the care/treatment/prescription is denied.

Sample Letter MN LetterOctober 30, 2009Community Health Network 11 Fairfield BoulevardWallingford, CT 06492Re: Pat Patient, 2/22/2004, Plan # 11111Greetings:I am writing to request authorization for Pat Patient to receive Pediasure for the

diagnosis of failure to thrive. This request is medically necessary because:KEY FACTS FOR PP INCLUDED HERE …

The provision of this important supplement will, or is reasonably expected to allow Pat to maintain health and functioning at her present level. Specifically (INCLUDE FACTS ABOUT PAT’s DIET ETC.)

If you need any further information, please do not hesitate to call me at (860) 714-1000. Very truly yours,

PCC ProviderLicense # 123456789PhoneFax

MN Advocacy – Appeal

Responses to Denials: HMO’s

Informally advocate with the UR rep. Informally advocate with the medical director

(usually not a pediatrician) Advise family to request an informal review Refer the family to the MLPP for formal appeal Formal appeal with DSS hearing officer (fair

hearing)

MN Advocacy – Appeal

Responses to Denials: DSS

Call the Medical Director (Rob Zavoski) Refer the case to the MLPP Initiate process of formal appeal (fair hearing)

Medical Necessity – A Review

The standard by which Medicaid care and treatment is judged

NOT a subjective standard – but subject to clinical judgment

Clinician has tools to advocate before the decision is made

Advocacy shifts burden to the decision maker

Make your case based on facts & details – don’t assume a denial is appropriate