Medicare Denied Claims: How the Appeal Letter Can Make or Break You

Medicare Denied Claims – How the Appeal Letter Can Make or Break You

HARMONY UNIVERSITY

The Provider Unit of

Harmony Healthcare International, Inc. (HHI)

Presented by:

Carrie Mullin, OTR/L, RAC-CTClaims Review Specialist

Harmony Healthcare International, Inc.

About Caroline

Claims Review Specialist for Harmony Healthcare International, Inc. MS OTR/L, RAC-CT Experience:

Extensive history with long term care as an Occupational Therapist, Director of Rehabilitation, and as Regional/Corporate Consultant for Harmony Healthcare. Specialized in working with facilities on preparing medical records for ADRs and appeals, as well as assisted facilities in preparation for ALJ hearings.Partnered with law firms to assist facilities with both internal and OIG investigations.

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Objectives

Learner will be able to summarize goals of Medicare Medical Review

Learner will be able to identify and articulate examples of documentation to support skilled nursing and rehabilitative care in the SNF

Learner will be able to identify strategies for interdisciplinary management of Medicare appeals

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Advice from Ben Franklin

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“Either write something worth

reading or do something worth

writing.”

“An ounce of prevention is

worth a pound of cure.”

Harmony Healthcare International, Inc. 4


Know Your Medicare Guidelines

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PREP Objective

One of the best ways to argue your facility provided skilled care to a patient is to outline the services provided and tie each one back to the Medicare guidelines that support them

Intermediaries tend to use blanket statements such as, “services were not reasonable and necessary” or “does not meet SNF care requirements”


PREP Objective

Your appeal letters should directly address potential areas for denial at the Additional Development Request (ADR) level

Explain how the services provided meet the definition of medically reasonable and necessary to stop the process in its tracks


Technical Denial Reasons

Response to Additional Documentation Request (ADR) did contain documentation requested

Documentation not received within requested time frame

Physician Certification not signed or missing

Therapy Billing logs do not support billingPart A – MDS Assessment

Part B - 8 Minute Rule

Illegible documentation

Hospital documentation was not submitted


Clinical Denial Reasons

Documentation did not support medical necessity

Documentation does not support daily skilled intervention by a qualified therapist

Documentation in the medical records must support continued progress


Denial Reasons

Services provided were likely clinically appropriate but the documentation provided to reviewers did not support:

Technical requirements

Medical necessity

The skills of a therapist were required

Functional outcome

Need to receive an inpatient level of care


Denial ReasonsReasonable and Necessary

The amount, frequency and duration of services were not reasonable, given the patient’s current status

ST documentation demonstrates that the therapist worked long enough with the beneficiary to develop a restorative program


Denial Reasons Skills of a Therapist

ST minutes were reduced based on clinical judgment because documentation did not support the billed minutes were reasonable and necessary. The beneficiary could not participate in self feeding during this period and required the speech therapist to assist with 100% of the feeding.

Documentation did not support medical necessity and need for continued skilled therapy. Patient needs assistance and supervision.


Denial ReasonsDeconditioning

Skills of a therapist are not required to maintain function or improve strength and endurance

Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation), do not constitute physical therapy services for Medicare purposes

Practicing of previously taught exercises does not require the skills of a therapist


Denial ReasonsRestorative Level of Care

Skilled therapy was provided when non-skilled maintenance services would have been more appropriate

Restorative level of care provided

Documentation supports that restorative nursing could have helped the beneficiary progress versus skilled rehabilitation services

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Denial ReasonsCustodial Level of Care

Example

Skilled rehabilitation and nursing services were custodial in nature and could have been met with restorative nursing, family member, or nursing provision of intermittent skilled rehabilitation and nursing services


Denial ReasonsPrior Level of Function

The therapist ignored the patient’s prior level of function and set unrealistic goals

Prior level of function was illegible. Prior level of function was blank.

Patient's functional level had not changed when compared to his prior level of functioning documented in the medical record

Weekly nursing progress notes demonstrate that the beneficiary required the same amount of assistance (extensive assistance) prior to and after the hospital stay


Denial ReasonsRehab Potential

The medical record did not support that the condition of the patient would improve materially in a reasonable and generally predictable period of time

Poor Rehab potential


Denial Reasons Goals

Goals are not functional (i.e., patient will perform 10 repetitions of upper extremity exercises with the yellow theraband)

Duplication of services between disciplines


Denial Reasons Lack of Functional Progress

Gains were not significant and there was no indication of carryover of the functional task

Lack of documentation relating to the patient having the potential to show significant progress

No significant improvement with functional ability

The outcome of therapy treatment was not documented

Failure to document a complete treatment plan as outlined in Documentation Required section


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Skilled Interventions

Medicare will support continued services when the patient is not making progress if there is documentation that multiple skilled interventions have been trialed

It is appropriate to give each trial an adequate amount of time to determine if the patient will progress

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Denial Reasons Modalities

Electrical Stimulation used to treat motor function disorders, such as multiple sclerosis, is considered investigational and therefore, non-covered

Electrical Stimulation used in the treatment of facial nerve paralysis, commonly known as Bell’s Palsy, is considered investigational and therefore, non-covered

Diathermy and Ultrasound heat treatments for the treatment of asthma, bronchitis, or any other pulmonary condition are considered not reasonable and necessary, and therefore, non-covered


Denial Reasons Cognitive Therapy

The record documented a diagnosis of Alzheimer’s disease. SLP documentation does not support further significant practical improvement could be expected.

Medical justification for ST services is not established

Speech treatment cognition for dementia

Poor progress with cognition


Denial ReasonsInpatient Level of Care

Documentation did not support the need for inpatient level of care

No daily skilled care requiring a stay in the SNF

Supervised level of care


Denial ReasonsMedical Record Conflicts

Nursing notes mostly dependent ADLs/functional tasks throughout the SNF stay. Nursing note indicated there was no improvement and fluctuation of progress with self-care tasks.

MDS assessments indicate that the beneficiary's ability to perform functional tasks/ADLs did not improve from the 5-day to the 90-day assessment


Documentation to Support Identified Risk Areas

Identify potential denial risk areas

What might the reviewer have not seen in the documentation provided to lead the reviewer to deny services?

What additional documentation may be included to further support skilled rehabilitation and nursing services provided?

Consultations/ED Visits

Care Plan

Physician Progress Notes

Social Services/Dietary Notes


What is Skilled Care?

Anchoring the Skill


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Medicare Requirements

The patient requires Skilled Nursing Services or Skilled Rehabilitation Services (i.e., services that must be performed by or under the supervision of professional or technical personnel) (See §214.1 – 214.3)



Medicare Eligibility

Treated for a condition which was treated during a qualified stay…or… which arose while in a SNF for a treatment of condition for which the beneficiary previously was treated in a hospitalFor Example:

Fractured hip develops pneumonia secondary to immobility



Medicare Requirements

The patient requires these skilled services on a daily basis (see §214.5)

Daily Nursing Notes

Treatment Sheets


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Skilled Rehabilitation

Medicare Benefit Policy Manual Chapter 8On a daily basisServices rendered are reasonable and necessaryMD orderedPractical matterAn appropriately licensed or certified individual must provide or directly supervise the therapeutic service and coordinate the intervention with nursing services

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Harmony Healthcare International

Medicare Benefit Policy Manual

Chapter 8 Revisions

December 2013


Why Update the Policy Manual?

CMS SettlementCMS revised the Medicare Benefit Policy Manual (December 2013) and will revise other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a beneficiary "improving"

New policy provisions state that skilled nursing and therapy services necessary to maintain a person's condition can be covered by Medicare


Medicare Benefit Policy Manual Update

“Coverage for such skilled therapy services does not turn on the presence or absence of a beneficiary’s potential for improvement from therapy services, but rather on the beneficiary’s need for skilled care. Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) These skilled services may be necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” - December 2013


Medicare Benefit Policy Manual Update

“The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that

The condition of the patient will improve materially in a reasonable and generally predictable period of time; or,

The services must be necessary for the establishment of a safe and effective maintenance program; or,

The services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program”

– December 2013


RAI User’s Manual Update

RAI User’s Manual September 2013:Therapy services can include the actual performance of a maintenance program in those instances where the skills of a qualified therapist are needed to accomplish this safely and effectively

However, when the performance of a maintenance program does not require the skills of a therapist because it could be accomplished safely and effectively by the patient or with the assistance of non-therapists (including unskilled caregivers), such services are not considered therapy services in this context


Jimmo v. Sebelius

The Jimmo v. Sebelius case challenged Medicare's use of an "Improvement Standard" to make coverage determinations

The lawsuit was brought on behalf of:

Six individuals representing a Nationwide class of Medicare beneficiaries

National organizations representing people with chronic conditions

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Individual Plaintiffs: Glenda Jimmo

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Paul O. Boisvert for New York Times

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Individual Plaintiffs

Lead plaintiff, Glenda Jimmo, is a 76-year-old Medicare beneficiary from Bristol, Vermont

Blind since birth and has had her right leg amputated due to complications from diabetes

Requires a wheelchair, and receives multiple home health care visits per week for various treatments for her complex condition

Medicare denied coverage for these services, saying that she was unlikely to improve


Individual Plaintiffs:Rosalie J. Berkowitz

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New York Times October 22, 2012

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Individual Plaintiffs

Rosalie J. Berkowitz is an 81-year-old Medicare beneficiary from Stamford, Connecticut

Multiple Sclerosis

Medicare denied coverage for home health visits and physical therapy on the grounds that her condition was not improving

Her family said she would have to go into a nursing home if Medicare did not cover the services


National Organizations

National Multiple Sclerosis Society

Parkinson’s Action Network

Paralyzed Veterans of America

Alzheimer’s Association

United Cerebral Palsy

National Committee to Preserve Social Security and Medicare, an advocacy group


Improvement Standard

The settlement addresses Medicare terminating or denying coverage to beneficiaries who are not improving for Medicare Part A and Part B



Plaintiffs alleged the “Improvement Standard”:

Is "a covert rule of thumb" that is not supported by the Medicare statute or regulations

Operates as an additional condition of eligibility which effectively denies beneficiaries coverage of certain skilled services



According to the Complaint, Medicare has:

Failed to make assessments regarding a beneficiary's "unique condition and individual needs"

Does not rely on the Medicare statute, regulations and manuals, but relies on "more restrictive internal guidelines, policies, and Local Coverage Determinations (LCDs)”


CMS Settlement

Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the "Improvement Standard" case, Jimmo v. Sebelius

A proposed settlement agreement was filed in Federal District Court on October 16, 2012

The Settlement was approved on January 24, 2013

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Jimmo v. Sebelius

The judgment indicates that as long as a patient requires skills of a therapist or a nurse, a patient would meet the skilled coverage criteria despite not making functional gains

Documentation must support the need for skilled therapy intervention



Know Your Reviewer




Medicare Administrative Contractors

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2003 mandated that the Secretary of Health & Human Services replace Part A FIs and Part B carriers with Medicare Administrative Contractors (MACs).

CMS established MACs as multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.



CMS relies on a network of MACs to process Medicare claims, and MACs serve as the primary operational contact between the Medicare Fee-For-Service program, and approximately 1.5 million health care providers enrolled in the program



Collectively, the MACs and the other Medicare claims administration contractors process nearly 4.9 million Medicare claims each business day, and disburse more than $365 billion annually in program payments



Centers for Medicare & Medicaid Services (CMS) contracts with Medicare Administrative Contractors (MACs) to assist with local claims processing and the first level appeals adjudication function



Under probe reviews, contractors may examine 20-40 claims per provider for provider-specific problems

Contractors also conduct widespread probe reviews (involving approx. 100 claims) when a larger problem, such as a spike in billing for a specific procedure, is identified



Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) included provision aimed at improving the Medicare fee-for-service appeals process

Part of the provisions mandate that all second-level appeals (for both Part A and Part B), also known as reconsiderations, be conducted by Qualified Independent Contractors (QICs)




Recovery Audit Contractors

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The Recovery Auditors Program Mission The Recovery Auditor detects and corrects past improper payments so that CMS can implement actions that will prevent future improper payments:

Providers can avoid submitting claims that do not comply with Medicare rules

CMS can lower its error rate

Taxpayers and future Medicare beneficiaries are protected

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If you bill fee-for-service programs, your claims will be subject to review by the Recovery Auditors

Target areas are posted on the RACs’ websites

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The Recovery Audit Review Process: Recovery Auditors review claims on a post-payment basis

Recovery Auditors use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs and the CMS Manuals

Three types of review:Automated (no medical record needed)

Semi-Automated (claims review using data and potential human review of a medical record or other documentation)

Complex (medical record required)

Recovery Audits look back three years from the date the claim was paid

Recovery Auditors are required to employ a staff consisting of nurses, therapists, certified coders and a physician CMD

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The appeal process for Recovery Audit denials is the same as the appeal process for Carrier/FI/MAC denials

“Discussion Period” by phone in the first 15 days of denial

If you disagree with the Recovery Auditor’s determination:

File within 30 days to avoid recoupment

Up to 120 days to appeal

Interest will still accrue during the appeal process

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ZPIC Audit

Frequency of Medical Review

Significant increase in frequency of Medical Review

Office of Inspector General (OIG) Reports

Department of Justice (DOJ) Review

Zone Program Integrity Contractor (ZPIC)

Recovery Audit Contractor (RAC)

Budget cuts

Expect to be Reviewed



Insulate, Insulate, Insulate!!!

Zone Program Integrity Contractor

(ZPIC)

CMS launched another major initiative to target providers other than the hospital setting as the RAC auditors have been focusing on hospital auditsSoutheast, South Central, Midwest, Northeast and West Coast regions of the U.S. are seeing the most ZPIC audits at this time


Zone Program Integrity Contractor (ZPIC)

ZPICs SafeGuard Services AdvanceMedHealth Integrity Integriguard

Surprise on-site visitsTargeted data analysisRandom audits100% pre-payment holds


On-site Medical Record Review Audits

AdvanceMedRequest for 160-170 Medical Records14 Days to SubmitRequesting ONLY Therapy DocumentationTherapy Staffing levels were requestedAdvanceMed interviews with Staff


ZPIC Audits

ZPIC targets are often selected based on

Unusual trends or changes in utilization over timeSpecific schemes noted by CMS that inappropriately maximize generated reimbursementReferrals from law enforcement and other sources for possible fraud and abuseHigh volume or high cost services that appear like they are being over-utilized


ZPIC Audit Targets

Providers with patients having unusually long lengths of service or high case mix levelsHHAs with patients having extended numbers of visitsHospice providers with high length-of-stay patients A SNF with a large volume of high “RUG” level claimsDisgruntled employee who threatened you as a “whistleblower”Operators in areas identified as high risk for fraud (Miami-Dade and Broward Counties)


ZPIC Audits

ZPICs are specifically allowed to

Place you on pre-payment reviewThe pre-payment review flag remains until a determination is issued on the audit, which can take a long time

Place you on billing suspensionWithhold payments


ZPIC Audits: What auditors demand at an unscheduled visit

Require proof that you are operating at the identified practice locationsInterview your staffRequired documentation that you meet conditions of participationSubmit a request for records, including:

Business recordsMedical records

Members of law enforcement can accompany ZPIC auditors


ZPIC Audits: How to Prepare?

Create or review your Compliance PlanHave an outside party conduct an annual coding accuracy reviewPerform data analysis to determine areas of exposureReview documentation proceduresTrain staff on how to respond to questions from ZPIC auditors



Rehab and MDS QuestionsSample therapy staff interview questions:1. Do you feel pressure to meet your

RUG levels?2. Who has the say on discharge from

therapy?



Sample MDS staff interview questions:1. Who decides the ARD?2. Do they provide group and

concurrent treatments?


Comprehensive Error Rate Testing

(CERT)


CERT Audits

CERT program monitors payments made by the MAC to the SNF

Each year, CERT evaluates a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules


CERT Process

Claim Selection

Medical Record Requests

Review of Claims

Assignment of Improper Payment Categories

Calculation of the Improper Payment Rate


CERT Process

A stratified random sample is taken by claim type: Part A and Part B

Claims are selected on a semi-monthly basis

The final CERT sample is comprised of claims that were either paid or denied by the MACs


CERT Process

The CERT Documentation contractor requests medical records from the provider or supplier that submitted the claim

If no documentation is received within 75 days of the initial request, the claim is classified as a “no documentation” claim and counted as an error

If documentation is received after 75 days of the initial request (late documentation), CERT will still review the claim


CERT Process

Reviews are conducted by nurses, medical doctors, and certified coders review the claims

Determinations are made regarding whether the claim was paid properly under Medicare coverage, coding, and billing rules

Improper payment categories are assigned


CERT Audits

Therapy Documentation: Missing/incomplete plan of care/treatment plan;

Missing Physician/Non-Physician Practitioner (NPP) signatures and dates;

Missing total time for procedures and modalities; and

Missing certification and recertification.


CERT Process

Improper Payment CategoriesNo Documentation

Insufficient Documentation

Medical Necessity

Incorrect Coding

Other


CERT Outcomes

If the error rate appears high, corrective actions can be put into place

Error Rate Reduction Plans

Allocate additional funds for representation at Administrative Law Judge (ALJ) hearings

Allocate additional funds to the MACs to increase their prepayment review on error-prone claim types

Educational programs for providers


PREP Objective

Each auditing agency has a slightly different agenda. Understand what their goals are.

Most auditing agencies hire nurses, therapists, and coding experts to review medical records

If your reviewer is a nurse or a coding expert, they may not see the skilled services the same way the therapy staff does


PREP Objective

A detailed PREP outlining the skilled services is imperative

Include definitions of standardized tests used, explanations of diet textures, details of specific procedures and techniques

Why a decline should be considered a “significant decline”?

Assume someone from another discipline may be reviewing the record and detail the PREP accordingly



Choose Your Details Wisely


PREP Outline

Outline the argument for coverageBrief explanation of the hospitalization (if one occurred)

Past medical history

Status of patient on admission

List of the skilled nursing services provided to the patient


PREP Outline

Appeal Letter

An explanation of skilled therapy services provided to the patient

Medicare guidelines used in the skilled care decision making process, if applicable


PREP Objective

Start with a basic framework of background information, daily skilled nursing services, and gains made in therapy.

Tie services back to the hospitalization

Tie services to conditions that arose in the SNF


PREP Objective

If there are no concrete gains made in therapy (i.e. progress from one level of assist to another), ensure additional details of another measureable benefit are included.

Be detailed! Consider the likely reasons for denial and address them head on.



Skills of a Therapist or a Nurse


Services must require the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or a nurse that qualified personnel, trained

caretakers or the patient cannot provide independently

Skills of a Therapist or a Nurse

Documentation must support:

Description of skilled treatment

Changes made to the plan of care due to assessment of the patient’s needs

Medical complexity

Why the clinical and critical thinking of a therapist or a nurse are required



Why is this material important?

Which team members should be aware of the Medicare Skilled Care criteria?

How often will this criteria be relevant to current beneficiaries and applicable for denied claims?

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Requires the skills of qualified technical or professional health personnel such as RN, LPN, PT, OT or SLP

Must be provided directly by or under the general supervision of a licensed nurse or skilled rehab personnel to assure the safety of the resident and to achieve the medically desired result

“General supervision” requires initial direction and periodic inspection of activity

Ordered by a physician

Services are needed and provided on a daily basis



The need for skilled care must be justified and documented in the medical record

Conditions may have prompted the initial hospitalization, but also include the conditions that arose during recovery in the SNF



What is Skilled Care ?

Direct Skilled Nursing ServicesManagement and Evaluation of a Care PlanObservation and AssessmentTeaching and TrainingSkilled Rehabilitation


Skilled Services Categories: Inherent Complexity

Inherent Complexity – Direct skilled nursing services including:

IV feeding

IV meds

Suctioning

Tracheostomy Care

Ventilator support

Ulcers


Skilled Services Categories: Inherent Complexity

Inherent Complexity

Tube feedings

Respiratory Therapy 7 days per week

Surgical wound or open lesions with treatments

Unstable clinically with diabetes with injections

Transfusions

Chemotherapy

Colostomy Care, early post-op care


Skilled Services Categories:Skilled Observation and Assessment

Reasonable probability or possibility for complication

Potential for further acute episodes

Identify and evaluate the need for modification of treatment

Evaluate initiation of additional medical procedures

Skilled observation can be required until the treatment regimen is essentially stabilized



Fever

Dehydration

Septicemia

Pneumonia

Nutritional Risk

Chemotherapy

Weight loss

Blood sugar control

Impaired cognition

Severe Mood and Behavior conditions

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Neurological

Respiratory

Cardiac

Circulatory

Pain/Sensation

Nutritional

Gastrointestinal

Genitourinary

Musculoskeletal

Skin



Identify and outline daily skilled nursing observations and assessments

Record DAILY each itemized area listed on your outline



If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services still are covered so long as there was reasonable probability for such a complication or further acute episode

“Reasonable probability” means that a potential complication or further acute episode is a likely possibility


Skilled Services Categories:Management and Evaluation of a Care Plan

Based on the physician’s orders, these services require the involvement of skilled nursing to meet the resident’s:

Medical needs

Promote recovery

Ensure medical safety


This area includes:

The sum total of unskilled services

Potential for serious complications

High probability of relapse

Recovery and safety

Meet medical needs

Includes resident’s overall condition





Topic Areas to include:Surgical sites

Circulatory status

Status of fractures

Maintenance of weight-bearing status

Skin Care

Labs

Consultant Recommendations


Skilled Services Categories: Management and Evaluation of a Care Plan

Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient’s condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient’s recovery and safety. The management of this plan of care requires skilled nursing personnel until the patient’s treatment regimen is essentially stabilized, even though the individual services involved are supportive in nature and not require skilled nursing personnel.


Skilled Services Categories: Teaching and Training

Teaching and Training: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen


Skilled Services Categories: Teaching and Training

Colostomy care

Insulin administration

Prosthesis management

Catheter care

G-tube feedings

IV access sites

Braces, splints and orthotics

Wound dressings and skin treatments

Medication management

Orthopedic precautions


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Skilled Rehabilitation

Medicare Benefit Policy Manual, Chapter 8On a daily basisServices rendered are reasonable and necessaryMD orderedPractical matterAn appropriately licensed or certified individual must provide or directly supervise the therapeutic service and coordinate the intervention with nursing services


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Skilled Rehabilitation/MD Involvement

The service must be ordered by a physician.

The therapy intervention must relate directly and specifically to an active written treatment regimen established by the physician after any needed consultation with the qualified rehabilitation therapy professional and must be reasonable and necessary to the treatment of the beneficiary’s illness or injury


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Skilled Rehabilitation/MD Involvement

MD involvement to prevent injuriesMedicare allows the professional therapist to develop a suggested plan of treatment and to begin providing services based on the plan prior to MD signatureMD signature required before facility bills Medicare.MD faxed signatures acceptable


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Skilled Rehabilitation Overview

Directly related to a written plan of treatmentRequires knowledge/skills/judgment of qualified professionalServices must be considered under acceptable standards clinical practiceExpectation of improvement of restorative potential in a reasonable and predictable period of time….or….Establishment of a safe and effective maintenance program


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Basic Criteria for Rehabilitation Services

Must be specifically related to the Physician’s Treatment Plan

Skill of a qualified therapist must be needed

Treatment plan must expect the patient to improve

Services must fall within accepted standards of medical practice and be specific to the patient

The services must be reasonable and necessary



Paint the Interdisciplinary Picture


PREP Objective

EXAMPLE: Your medical record may have a note from the Dietary Department documenting poor intake, an MD note referencing low blood sugars, a Braden score that qualifies the patient as high risk for skin breakdown, and nursing notes that reflect encouragement for out of bed activities.


PREP Objective

Your PREP needs to take all of those elements of the medical record and paint the interdisciplinary picture of care:

How do all of those items interrelate?

What were the risk factors for not having daily nursing care?

How does the combination of those services elevate the patient to a skilled level of care?

Management and evaluation of the Care Plan



To paint an interdisciplinary picture, you must work as an

interdisciplinary TEAM!


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What To Do When You Get An ADR

Help Letters and Appeals

In order to effectively manage a Medicare Help Letter or denied claim, the facility must work as a team to gather pertinent information

Assign a team leader to oversee the preparation of the ADR/appeal package

All members of the team should review the medical record to ensure completeness



The following team members are beneficial in this process:

MDS Coordinator

Director of Nursing Unit Managers (consider)

Restorative Nursing program Manager

Director of Therapy Any therapy professionals involved in the patient’s care

Social Services

Dietary

Additional team members who participated in care



Many times the process starts with an Additional Development Request (ADR)

These can be triggered by items specific to the patient, such as:

RUG score

ICD-9 code billed

Widespread probe



It is important to read the ADR or denial letter thoroughly as the letters will assist the facility in gathering the appropriate information

Review the list of items provided in the decision statement to include in the medical record

Consider additional info not listed that will support the services provided


The Appeal Package

List of items typically requested:Initial MDS and any MDS that corresponds to the billed dates of service and look back

All physician documentation for dates of service in question

Physician’s orders

MD certifications

MD progress notes

History and Physical


The Appeal Package

Items to includeInclude all information in the medical record from the look back period

MD re-certifications for skilled stay for billed dates:

If certification is signed by a NP, be aware that there may be a request for the facility to submit an attestation letter verifying no direct or indirect employment relationship with the SNF


The Appeal Package

Items to include Pre-admission data

Hospital records that validate a qualifying stay

Daily nurses notesMDSC notes

Case Manager notes

Care Plan

MAR and TAR


The Appeal Package

Items to include Documentation of all therapies provided

Evidence of MD supervision

Evaluations

Progress notes and

Therapy billing logs

Any other documentation that relates to the condition for which services were rendered that skilled the patient for Medicare Part A services in the Skilled Nursing Facility


The Appeal Package

Items to include Diagnostic testing and lab work

Documentation of adjustment to HIPPS codes resulting from MDS corrections

Signature log for all staff members documenting in the medical record during the dates in question, including printed name, credentials and handwritten signatures


The Appeal Package

Each team member should review the package as a whole

The team leader should have a final look prior to submitting the appeal

PREP Letter Proper Reimbursement Explanation Paper

Always keep a copy of the packet sent to the reviewing agency


How Does Your Team Measure Up?

Take the Harmony Healthcare International (HHI) Denied Claims Appeals Process

Proficiency Exam

http://cdn2.hubspot.net/hub/56632/file-285885026-pdf/DenialGraderWB.pdf


https://app.getsignals.com/link?url=http://cdn2.hubspot.net/hub/56632/file-285885026-pdf/DenialGraderWB.pdf&userkey=agxzfnNpZ25hbHNjcnhyGAsSC1VzZXJQcm9maWxlGICAgIDm3_QIDA&k=f6dcc0118f1341999d62ff56b6eae9c3

https://app.getsignals.com/link?url=http://cdn2.hubspot.net/hub/56632/file-285885026-pdf/DenialGraderWB.pdf&userkey=agxzfnNpZ25hbHNjcnhyGAsSC1VzZXJQcm9maWxlGICAgIDm3_QIDA&k=f6dcc0118f1341999d62ff56b6eae9c3

ADR/Help Letter Checklist


HELP LETTER REVIEW CHECK LIST Period Skilled Nursing Chart Review: From: __________________ To: _________________ Medicare Admission Date: ___________ Diagnosis: ________________________________

MDS Reference Dates Review

5 day 14 day 30 day 60 day 90 day

SOT/EOT OMRA

ARD Billing Dates

RUG/HIPPS

COT COT COT COT COT COT ARD Billing Dates

RUG/HIPPS

ICD-9 Codes __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


All Medical Records Are Different


PREP Objective

Intermediaries review a record in about 10 minutes, which does not leave much time to learn and understand your facility’s documentation techniques

Your PREP is the perfect tool to guide reviewers through your medical record

Reference specific dates and documents when describing the skilled care provided

Reference specific page numbers.


Appeals Process

Set up your medical record to tell the story you want told

Dividers and table of contents

Highlight

Sticky tabs





Appealing Medicare

Denied Claims


Appeal Process

Common practice to receive communications from Medicare review agencies requesting proof of skilled services

Understand the process to manage the inquiry in a timely and detailed manner in order to minimize lost revenue


Appeal Process

It is not uncommon for an ADR to result in the denial of part or all of a claim

Once an initial claim determination is made providers have the right to appeal


Monitor the Appeal

Internal tracking system to monitorWhen ADR or denial was received

When package was sent out

Final results of the review


Appeal Rights

RedeterminationA review of the claim by the MAC utilizing personnel who are different from the personnel who made the initial determination

The appellant (individual filing the appeal) has 120 days from the date of receipt of initial denial to file an appeal

A minimum monetary threshold is not required to request a redetermination


Appeal Rights

ReconsiderationIf the facility is dissatisfied with result of redetermination, they may request a reconsideration

A Qualified Independent Contractor (QIC) will conduct the reconsideration

The reconsideration process is an independent review of medical necessity by a panel of physicians or other health care professionals

A minimum monetary threshold is not required to request a reconsideration


Appeal Rights

ALJ HearingIf at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration

The facility must also send a notice of the ALJ hearing request to the QIC and verify this on the hearing request form or in the written request


ALJ Overview

After the redetermination and reconsideration process, if at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration

Combine claims to reach $130 if necessary

The facility must send a notice of the ALJ hearing request to the QIC on the hearing request form or in the written request


ALJ Overview

A letter to request the ALJ hearing should simply highlight the most pertinent reasons justifying payment


In Conclusion

Provide clinically appropriate care

Meet technical requirements

Document Medical necessity

Deficits

Outcomes

Establish and maintain peer review and external review of records to assure insulation of claims


In Conclusion

Raise facility awareness

Function as a TEAM

Communicate and be organized

Review entire medical record

Respond to ADRs timely


Questions/Answers

Harmony Healthcare International1 (800) 530 – [email protected]


mailto:[email protected]


Harmony Healthcare International (HHI)

For attending this seminar, you are eligible for one of the following:

Free PEPPER Analysis

Free RUGS Analysis

Assess your facility against key indicators and national norms.

Contact us at:

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Analysis is cost & obligation free

Harmony Healthcare International, Inc. 145Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved



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