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-CT Claims Review Specialist

Harmony Healthcare International, Inc.

About CarolineClaims 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.

Copyright 2014 All Rights Reserved 2


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

3Copyright 2014 All Rights Reserved


Advice from Ben Franklin

Copyright © 2014 All Rights Reserved

“Either write something worth reading or do

something worth writing.”

“An ounce of prevention is worth a

pound of cure.”4



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Know Your Medicare Guidelines



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 billing

Part 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



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 InterventionsMedicare 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



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)

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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 hospital For 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 8 On a daily basis Services rendered are reasonable and necessary MD ordered Practical matter An 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

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Medicare Benefit Policy Manual Chapter 8 Revisions

December 2013



Why Update the Policy Manual?

CMS Settlement CMS 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


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


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



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




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Know Your Reviewer


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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)




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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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Recovery Audit ContractorsThe 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 audits Southeast, 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 AdvanceMed Health Integrity Integriguard

Surprise on-site visits Targeted data analysis Random audits 100% pre-payment holds


On-site Medical Record Review Audits

AdvanceMed Request for 160-170 Medical Records 14 Days to Submit Requesting ONLY Therapy Documentation Therapy Staffing levels were requested AdvanceMed interviews with Staff


ZPIC Audits

ZPIC targets are often selected based on Unusual trends or changes in utilization over time Specific schemes noted by CMS that inappropriately maximize generated reimbursement Referrals from law enforcement and other sources for possible fraud and abuse High 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 levels HHAs with patients having extended numbers of visits Hospice providers with high length-of-stay patients A SNF with a large volume of high “RUG” level claims Disgruntled 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 review

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

Place you on billing suspension Withhold payments


ZPIC Audits: What auditors demand at an unscheduled visit

Require proof that you are operating at the identified practice locations Interview your staff Required documentation that you meet conditions of participation Submit a request for records, including:

Business records Medical records

Members of law enforcement can accompany ZPIC auditors


ZPIC Audits: How to Prepare?

Create or review your Compliance Plan Have an outside party conduct an annual coding accuracy review Perform data analysis to determine areas of exposure Review documentation procedures Train staff on how to respond to questions from ZPIC auditors



Rehab and MDS Questions Sample 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?



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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 Categories No Documentation Insufficient Documentation Medical Necessity Incorrect Coding Other



CERT OutcomesIf 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 coverage Brief 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



What is Skilled Care? 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


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What is Skilled Care ?

Direct Skilled Nursing Services Management and Evaluation of a Care Plan Observation and Assessment Teaching and Training Skilled 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:

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



Skilled Services Categories:Skilled Observation and Assessment

Fever Dehydration Septicemia Pneumonia Nutritional Risk

Chemotherapy Weight loss Blood sugar control Impaired cognition Severe Mood and Behavior conditions




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

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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 8 On a daily basis Services rendered are reasonable and necessary MD ordered Practical matter An 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 injuries Medicare allows the professional therapist to develop a suggested plan of treatment and to begin providing services based on the plan prior to MD signature MD signature required before facility bills Medicare. MD faxed signatures acceptable


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Skilled Rehabilitation Overview

Directly related to a written plan of treatment Requires knowledge/skills/judgment of qualified professional Services must be considered under acceptable standards clinical practice Expectation 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



Help Letters and AppealsThe 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 include Include 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 notes MDSC 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


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







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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 monitor When ADR or denial was received When package was sent out Final results of the review



Appeal Rights

Redetermination A 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

Reconsideration If 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 Hearing 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 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 International 1 (800) 530 – 4413 [email protected]


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Harmony Healthcare International (HHI)

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