SlideShare una empresa de Scribd logo
1 de 133
Descargar para leer sin conexión
How to Review the
SNF Appeal Process
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.
Speaker Bio (Caroline Mullin)
Director of Denial Services for Harmony Healthcare
International, Inc. and Corporate Consultant for HHI
since 2008
MS OTR/L, RAC-CT
Education:
Masters of Science in Occupational Therapy from
Spalding University in Louisville, KY
Continuing Education in Contracture and Geriatric
Therapeutic Exercise Courses
Experience:
Senior Occupational Therapist and Director of
Rehabilitation Services at Episcopal Senior Life
Communities in Rochester, NY
Expert in Denials, Appeal letters, and prepping
facilities for ALJ hearings
Copyright © 2014 All Rights Reserved 2
Objectives
Learner will be able to summarize SNF
Medicare qualifiers
Learner will be able to articulate Audit Triggers
Learner will be able to Summarize Medical
Record Preparedness
Learner will be able to Summarize the ADR
and appeal process
Learner will be able to articulate strategies for
participation in ALJ Hearings
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 3
Documenting Medicare Skilled
Coverage Requirements
DEFENSE!!
Copyright © 2014 All Rights Reserved 4Harmony Healthcare International, Inc.
The KEY to Preventing Denials
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.”
5Harmony Healthcare International, Inc.
Prevention
The key to preventing denials is
documentation of skilled services
provided
The key to documenting skilled services
provided is understanding the
Medicare requirements for coverage
Copyright © 2014 All Rights Reserved 6Harmony Healthcare International, Inc.
The Importance of Documentation
The key to ensuring accurate
reimbursement for services
provided is understanding skilled
coverage requirements
Copyright © 2014 All Rights Reserved 7Harmony Healthcare International, Inc.
Medicare Manual Source Document
Medicare Benefit Policy Manual
Chapter 8 - Coverage of Extended Care
(SNF) Services Under Hospital
Insurance (Rev. 175, 12-06-13)
Effective 1/7/14
Copyright © 2014 All Rights Reserved 8Harmony Healthcare International, Inc.
Medicare Coverage/Skilled Care
Provided on a “daily” basis:
Skilled nursing (or combination of
nursing and rehabilitation) must be seven
days per week
Skilled restorative nursing must be at
least six days per week
Rehabilitation (PT, OT and/or SLP) must
be at least five days per week
An isolated break of “a day or two” is
allowable
Copyright © 2014 All Rights Reserved 9Harmony Healthcare International, Inc.
Chapter 8 Medicare Manual (2014)
Rehabilitation Daily
Single type of skilled rehabilitation every day, or by
furnishing various types of skilled services on
different days that collectively add up to “daily”
skilled services. “Arbitrarily staggering the timing of
various therapy modalities though the week, merely
in order to have some type of therapy session occur
each day, would not satisfy the SNF coverage
requirement for skilled care to be needed on a “daily
basis.” To meet this requirement, the patient must
actually need skilled rehabilitation services to be
furnished on each of the days that the facility
makes such services available “
Copyright © 2014 All Rights Reserved 10Harmony Healthcare International, Inc.
What is Skilled Care?
Nature of service requires the skills of a
licensed person (e.g. technical or
professional personnel)
Skilled services are provided directly by or
under general supervision of a licensed
nurse or therapist to assure the safety of the
patient and to achieve the medically desired
result
Diagnosis and prognosis do not determine
what is skilled care – it is the care of the
patient that is the deciding factor
Copyright © 2014 All Rights Reserved 11Harmony Healthcare International, Inc.
“Practical Matter” Criterion
“As a practical matter,
considering economy and
efficiency, the daily skilled
services can only be provided
in a skilled nursing facility”
Copyright © 2014 All Rights Reserved 12Harmony Healthcare International, Inc.
“Practical Matter” Criterion
1. Outpatient services are not available in
the area where the individual lives
2.Outpatient services are available in the
area where the individual lives, but
transportation to the closest facility
could cause an excessive physical
hardship, be less economical, or less
effective than placement in the skilled
nursing facility
Copyright © 2014 All Rights Reserved 13Harmony Healthcare International, Inc.
“Practical Matter” Criterion
3. The availability at home of a capable and willing
caregiver should be considered, but the care can
be furnished only in the skilled nursing facility if
home care would be ineffective because there
would be insufficient assistance at home for the
patient/patient to reside there safely
4. If the use of alternative services would
adversely affect the patient/patient’s medical
condition, then as a practical matter the daily
skilled service(s) can only be provided on an
inpatient basis
Copyright © 2014 All Rights Reserved 14Harmony Healthcare International, Inc.
Basic Medicare Requirements
If any one of these three factors is not
supported by the documentation in the
patient’s record, the SNF stay, even
though it might include the delivery of
daily skilled services, will not be
covered.
Copyright © 2014 All Rights Reserved 15Harmony Healthcare International, Inc.
RUG-IV
Resource Utilization Groups
Each MDS qualifies for multiple RUGs,
and the software automatically chooses
the highest reimbursement rate
Rehabilitation Intensity, Diagnoses,
Nursing Services, and ADLs all
contribute
Documentation must support all coding
on the MDS 3.0 assessment
Copyright © 2014 All Rights Reserved 16Harmony Healthcare International, Inc.
Presumption of Coverage
Medicare beneficiaries who are correctly
assigned to one of the upper 52 RUG-IV
groups on the initial 5-Day, Medicare
required assessment are automatically
classified as meeting the SNF level of care
definition up to and including the assessment
reference date on the 5-day Medicare-
required assessment
Only applies when admitted from Acute
Care Hospital (Not Swingbed or another
SNF)
Copyright © 2014 All Rights Reserved 17Harmony Healthcare International, Inc.
Presumption of Coverage
This presumption recognizes the strong
likelihood that beneficiaries assigned to
one of the upper 52 RUG-IV groups
during the immediate post-hospital
period require a covered level of care,
which would be less likely for those
beneficiaries assigned to one of the
lower 14 RUG-IV groups
Copyright © 2014 All Rights Reserved 18Harmony Healthcare International, Inc.
Presumption of Coverage
This administrative presumption policy
does not supersede the SNF’s
responsibility to ensure that its
decisions relating to level of care are
appropriate and timely, including a
review to confirm that the services
prompting the beneficiary’s assignment
to one of the upper 52 RUG-IV groups
Copyright © 2014 All Rights Reserved 19Harmony Healthcare International, Inc.
Totality
While it is true that dialysis is one of the
discrete indicators for assignment to a RUG
within the Special Care Low category – a
category to which the level of care
presumption applies for a short period of
time at the start of a SNF stay – it is the
totality of items and services included
within a given RUG, not any one specific
coded service, that actually serves to justify
the presumption
Copyright © 2014 All Rights Reserved 20Harmony Healthcare International, Inc.
What is Skilled Care ?
Direct Skilled Nursing Services
Management and Evaluation of a Care
Plan
Observation and Assessment
Teaching and Training
Skilled Rehabilitation
Copyright © 2014 All Rights Reserved 21Harmony Healthcare International, Inc.
What is Skilled Care?
Nursing Anchors the Skill
Need to remain in a SNF
Medical Complexity
Supports Non-Therapy RUG
Increased potential Lower 14
and reviews with October 1st
Changes
Copyright © 2014 All Rights Reserved 22Harmony Healthcare International, Inc.
Skilled Services Categories:
Nursing Inherent Complexity
Inherent Complexity – Direct skilled
nursing services including:
IV feeding
IV meds
Suctioning
Tracheostomy Care
Ventilator support
Ulcers
Copyright © 2014 All Rights Reserved 23Harmony Healthcare International, Inc.
Skilled Services Categories:
Nursing 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
Copyright © 2014 All Rights Reserved 24Harmony Healthcare International, Inc.
Observation and Assessment
Skilled services when the likelihood of change
in a patient’s condition requires skilled
nursing or skilled rehabilitation personnel to
identify and evaluate the patient’s need for
possible modification of treatment or
initiation of additional medical procedures,
until the patient’s condition is essentially
stabilized. Reasonable potential for a future
complication or acute episode sufficient to
justify the need for continued skilled
observation and assessment.
Copyright © 2014 All Rights Reserved 25Harmony Healthcare International, Inc.
Observation and Assessment
Example (from Chapter 8 of the
Medicare Benefit Policy Manual):
A patient has been hospitalized
following a heart attack, and
following treatment but before
mobilization, is transferred to the
SNF
Copyright © 2014 All Rights Reserved 26Harmony Healthcare International, Inc.
Observation and Assessment
Example (continued): Because it is
unknown whether exertion will
exacerbate the heart disease,
skilled observation is reasonable
and necessary as mobilization is
initiated, until the patient’s
treatment regimen is essentially
stabilized
Copyright © 2014 All Rights Reserved 27Harmony Healthcare International, Inc.
Observation and Assessment
The medical documentation must
describe the skilled services that require
the involvement of nursing personnel to
promote the stabilization of the
patient's medical condition and safety
(Effective 1/2014).
Copyright © 2014 All Rights Reserved 28Harmony Healthcare International, Inc.
Observation and Assessment
KEY POINT: If a patient was admitted
for skilled observation but did not
develop a further acute episode or other
complications, the skilled observation
services still are covered so long as
there was a reasonable probability for
such a complication or further acute
episode
Copyright © 2014 All Rights Reserved 29Harmony Healthcare International, Inc.
Observation and Assessment
Fever
Dehydration
Septicemia
Pneumonia
Nutritional Risk
Chemotherapy
Weight loss
Blood sugar control
Impaired cognition
Severe Mood and
Behavior conditions
Copyright © 2014 All Rights Reserved 30Harmony Healthcare International, Inc.
Observation and Assessment
Neurological
Respiratory
Cardiac
Circulatory
Pain/Sensation
Nutritional
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Copyright © 2014 All Rights Reserved 31Harmony Healthcare International, Inc.
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
Copyright © 2014 All Rights Reserved 32Harmony Healthcare International, Inc.
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
Copyright © 2014 All Rights Reserved 33Harmony Healthcare International, Inc.
Copyright © 2014 All Rights Reserved
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 of clinical practice.
Expectation of improvement of restorative
potential in a reasonable and predictable
amount of time…or…
Establishment of a safe and effective
maintenance program.
34Harmony Healthcare International, Inc.
Copyright © 2014 All Rights Reserved
Medicare Benefit Policy
The services shall be of such a level of
complexity and sophistication or the
condition of the patient shall be such
that the services required can be safely
and effectively performed only by a
therapist.
35Harmony Healthcare International, Inc.
Harmony Healthcare International, Inc.
36
Maintenance Therapy
Maintenance Therapy. The repetitive services
required to maintain function sometimes involve
the use of complex and sophisticated therapy
procedures and consequently, the judgment and
skill of a physical therapist might be required for
the safe and effective rendition of such services (see
§214.1.B).
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 (Effective 1/2014).
Copyright © 2014 All Rights Reserved 36Harmony Healthcare International, Inc.
Maintenance Therapy
Therapy services in connection with a maintenance
program 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) If all other requirements for coverage under
the SNF benefit are met, skilled therapy services are
covered when an individualized assessment of the
patient’s clinical condition demonstrates that the
specialized judgment, knowledge, and skills of a
qualified therapist are necessary for the performance
of a safe and effective maintenance program.
Copyright © 2014 All Rights Reserved 37Harmony Healthcare International, Inc.
Jimmo v. Sebelius
The Jimmo v. Sebelius lawsuit was brought
on behalf of a nationwide class of Medicare
beneficiaries by six individual Medicare
beneficiaries and seven national
organizations representing people with
chronic conditions
The Jimmo v. Sebelius case challenged
Medicare's use of an "Improvement
Standard" to make coverage determinations
Copyright © 2014 All Rights Reserved 38Harmony Healthcare International, Inc.
Jimmo v. Sebelius
On January 24, 2013, a settlement was
approved by the federal district court in
Vermont in the case of Jimmo v. Sebelius
regarding the "Improvement Standard"
Addresses the ability to terminate or
deny coverage to beneficiaries who are
not improving for Medicare Part A and
Part B
Copyright © 2014 All Rights Reserved 39Harmony Healthcare International, Inc.
Jimmo v. Sebelius
Expands Medicare Part A and Part B
coverage to include the rendering of
skilled nursing and therapy services
necessary to maintain a person's
condition and is not dependent on
whether the Medicare beneficiary “will
improve”.
CMS Fact Sheet States this is simply a
clarification
Copyright © 2014 All Rights Reserved 40Harmony Healthcare International, Inc.
Jimmo v. Sebelius
The judgment indicates that as long as a
patient requires skills of a therapist or a
nurse a patient would meet skilled
coverage criteria despite not making
functional gains
Documentation must support the need
for skilled therapy intervention
Copyright © 2014 All Rights Reserved 41Harmony Healthcare International, Inc.
Skills of a Therapist or a Nurse
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
Copyright © 2014 All Rights Reserved 42Harmony Healthcare International, Inc.
Skilled Nursing Documentation
What To Consider Including
Patient is at high risk for …
Skilled assessment of …
Daily skilled monitoring of …
Potential for recurrence of …
Potential for the following complications…
There is a likelihood of change related to…
The medical regimen is not essentially
stabilized as evidenced by…
Copyright © 2014 All Rights Reserved 43Harmony Healthcare International, Inc.
Skilled Nursing Documentation
What To Consider Including
Patient continues to require daily skilled rehab
for …
Observation and assessment for potential
complications related to …
Potential for medical complications related to
the diagnosis of …
Plan of care is being monitored to promote
recovery and ensure medical safety related to …
The patient requires daily skilled management
and evaluation of the plan of care related to …
Copyright © 2014 All Rights Reserved 44Harmony Healthcare International, Inc.
Skilled Nursing Documentation
What To Consider Including
Skilled neurological assessment resulted in…
Daily skilled monitoring for signs and symptoms
of exacerbation of _____ secondary to _______
Patient is high risk for ______ secondary to
_______
Medications adjusted to _____________, ongoing
skilled assessment of regimen to promote
recovery and ensure medical safety
Patient continues to require daily skilled nursing
as his treatment regimen is not essentially
stabilized and there is a potential for recurrence
of ________
Copyright © 2014 All Rights Reserved 45Harmony Healthcare International, Inc.
Non-Supportive Nursing
Documentation
Plateau in progress
Voiced no complaints
Patient requires custodial
care
Patient requires
intermittent care
Patient is unable to
follow directions
Patient requires
intermittent services
Patient has poor
rehabilitation potential
Patients medical
treatment is essentially
stabilized
Refuses to participate in
therapy (instead give the
reason the patient is
unable)
Condition stable
Slept well/family into
visit
Copyright © 2014 All Rights Reserved 46Harmony Healthcare International, Inc.
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 47Harmony Healthcare International, Inc. 47
Recovery Audit Contractors
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 48Harmony Healthcare International, Inc. 48
Recovery Audit Contractors
The Recovery Auditors Program Mission
The Recovery Auditor detect and correct 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.
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 49Harmony Healthcare International, Inc. 49
Recovery Audit Contractors
If you bill fee-for-service programs, your
claims will be subject to review by the
Recovery Auditors.
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 50Harmony Healthcare International, Inc. 50
Recovery Audit Contractors
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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 51Harmony Healthcare International, Inc. 51
Recovery Audit Contractors
The appeal process for Recovery Audit denials
is the same as the appeal process for
Carrier/FI/MAC denials
Do not confuse the “Recovery Audit Programs’
Discussion Period” with the Appeals process
If you disagree with the Recovery Auditor’s
determination:
Do not stop with sending a discussion letter
File an appeal before the 120th day after the Demand
letter.
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 52Harmony Healthcare International, Inc. 52
Recovery Audit Contractors
Recovery Auditors will offer an opportunity for
the provider to discuss the improper payment
determination with the Recovery Auditors (this
is outside the normal appeal process)
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 53Harmony Healthcare International, Inc. 53
Appeal Determinations
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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 54
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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 55
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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 56
Denial Reasons
Reasonable 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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 57
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.
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 58
Denial Reasons
Deconditioning
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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 59
Denial Reasons
Restorative 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
60Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
Denial Reasons
Custodial Level of Care
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 and that needs were
custodial in nature and could have been
met with restorative nursing, family
member, or nursing assistant
61Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
Denial Reasons
Prior 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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 62
Denial Reasons
Rehab 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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 63
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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 64
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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 65
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 66
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
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
67Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 68
Denial Reasons
Inpatient 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
69Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
Denial Reasons
Medical 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
70Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
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
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 71
Appeal Process
Harmony Healthcare International, Inc. 72Copyright © 2014 All Rights Reserved
Appeal Rights
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 73
Appeal Rights
Right to Appeal:
If the Beneficiaries is the only one with the right to
appeal given specific situations, provider must
obtain transfer from beneficiary
Beneficiaries may transfer appeal rights to
providers who provide the items or services and
do not otherwise have appeal rights
Form CMS-20031 must be completed and signed
by the beneficiary and supplier to transfer the
beneficiary’s appeal rights
Harmony Healthcare International, Inc. 74Copyright © 2014 All Rights Reserved
Appeal Rights
Right to Appeal
All appeal requests must be
made in writing
Harmony Healthcare International, Inc. 75Copyright © 2014 All Rights Reserved
Appeal Rights
Medicare offers five levels in the Part A and Part
B Appeals Process:
1. Redetermination by a MAC
2. Reconsideration by a QIC
3. Hearing by an Administrative Law Judge
(ALJ)
4. Review by the Medicare Appeals Council,
within the Department Appeals Board
5. Judicial review in U.S. District Court
Harmony Healthcare International, Inc. 76Copyright © 2014 All Rights Reserved
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
Harmony Healthcare International, Inc. 77Copyright © 2014 All Rights Reserved
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
Harmony Healthcare International, Inc. 78Copyright © 2014 All Rights Reserved
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
Harmony Healthcare International, Inc. 79Copyright © 2014 All Rights Reserved
Harmony Healthcare International
ADR Response
And
Appeal Packages
Harmony Healthcare International, Inc. 80Copyright © 2014 All Rights Reserved
Additional Development Requests
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 81
Additional Development Requests
Medicare Contractors send providers
additional development request (ADR)
letters requesting additional
documentation
The ADR letters will be mailed and /or
the claim in question will be in status
location S B6001 that identifies claims in
FISS that are in an ADR status/location
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 82
Additional Development Requests
Do not submit replacement/duplicate
claims for the ones pending in medical
review
The submission of
replacement/duplicate claims will result
in claim denial, rejection or recoupment
This will p r o l o n g the medical
review process
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 83
Additional Development Requests
When the claim is finalized, the claim
will have paid in full or part, or denied
If you disagree with the decision, you
can request a redetermination/1st level
of appeal within 120 days of the
determination (date on the remittance
advice)
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 84
Additional Development Requests
After the 45th day, if the documentation
needed to make a medical
determination is not received, the claim
may be denied as records not received
timely and these claim denials are
issued with Remittance Advice Code
N102/56900
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 85
Additional Development Requests
CMS guidelines allow contractors the
time frame of 60 days to complete the
review from the date on which the last
of the requested medical records is
received
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 86
Harmony Healthcare International
The Appeal
Harmony Healthcare International, Inc. 87Copyright © 2014 All Rights Reserved
The Appeal
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 88
Assign a team leader to oversee the
preparation of the denial package
Work as a team to gather pertinent
information for the Medicare Appeal
Review the medical record to ensure
completeness
The Appeal
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
Harmony Healthcare International, Inc. 89Copyright © 2014 All Rights Reserved
Monitor the Appeal
Internal tracking system to monitor
When ADR or denial was received
When package was sent out
Final results of the review
Harmony Healthcare International, Inc. 90Copyright © 2014 All Rights Reserved
The Appeal
In order to effectively manage a Medicare
denial, the facility must work as a team to
gather pertinent information
Assign a team leader to oversee the
preparation of the denial package
All members of the team should review the
medical record to ensure completeness
Harmony Healthcare International, Inc. 91Copyright © 2014 All Rights Reserved
The Appeal
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
Harmony Healthcare International, Inc. 92Copyright © 2014 All Rights Reserved
The Appeal
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 listed in the
ADR/decision statement to include in the
medical record
Consider additional info not listed that will
support the services provided
Harmony Healthcare International, Inc. 93Copyright © 2014 All Rights Reserved
ADR/Help Letter Checklist
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 94
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
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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
Harmony Healthcare International, Inc. 95Copyright © 2014 All Rights Reserved
The Appeal Package
Important to know the consequences if
the facility does not submit all
necessary paperwork
Facility needs to review the packet
carefully to avoid a technical denial based
on missing information including
signatures
Harmony Healthcare International, Inc. 96Copyright © 2014 All Rights Reserved
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
Harmony Healthcare International, Inc. 97Copyright © 2014 All Rights Reserved
Appeals Process
PREP
Include a statement of position letter with
the medical record documentation to the
reviewing agency explaining the services
provided to the patient
Harmony Healthcare International, Inc. 98Copyright © 2014 All Rights Reserved
Monitor the Appeal
Harmony Healthcare International, Inc. 99Copyright © 2014 All Rights Reserved
Monitor the Appeal
Internal tracking system to monitor
When ADR or denial was received
When package was sent out
Final results of the review
Harmony Healthcare International, Inc. 100Copyright © 2014 All Rights Reserved
Harmony Healthcare International
Redetermination
and
Reconsideration
Harmony Healthcare International, Inc. 101Copyright © 2014 All Rights Reserved
Redetermination and Reconsideration
If a claim is initially denied, there is
action the facility can take
The first stage is the Redetermination
The next step is a Reconsideration
Harmony Healthcare International, Inc. 102Copyright © 2014 All Rights Reserved
Redetermination
An examination of a claim by a review
agency who is different from the agency
who made the initial determination
The facility has 120 days from the date
of receipt of the initial claim
determination to file an appeal
A minimum monetary threshold is not
required to request a determination
Harmony Healthcare International, Inc. 103Copyright © 2014 All Rights Reserved
Redetermination
Include an appeal letter that outlines
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
Harmony Healthcare International, Inc. 104Copyright © 2014 All Rights Reserved
Redetermination
Appeal Letter
An explanation of skilled therapy
services provided to the patient
Medicare guidelines used in the
skilled care decision making process,
if applicable
Harmony Healthcare International, Inc. 105Copyright © 2014 All Rights Reserved
Redetermination
Any additional supporting documentation
not submitted during the Help letter phase
from the medical record should be submitted
along with the redetermination request
Highlight
Add sticky tabs
The redetermination request should be sent
to the contractor that issued the initial
determination
Harmony Healthcare International, Inc. 106Copyright © 2014 All Rights Reserved
Redetermination
Contractors will generally issue a
decision within 60 days of receipt of
redetermination request in the form of :
A letter
A Medicare Redetermination Notice
(MRN)
Revised remittance advice
Harmony Healthcare International, Inc. 107Copyright © 2014 All Rights Reserved
Reconsideration
If the request for redetermination results in a
denial, a reconsideration can be requested
A QIC will conduct the reconsideration
request
The QIC reconsideration process allows for
an independent review of medical necessity
by a panel of physicians or other health-care
professions
A minimum monetary threshold is not
required to request a reconsideration
Harmony Healthcare International, Inc. 108Copyright © 2014 All Rights Reserved
Reconsideration
A written reconsideration request must
be filed within 180 days of receipt of the
redetermination
Instructions are provided on the
Medicare Redetermination Notice
(MRN)
A Request for reconsideration may be
made on Form CMS-20033. This form
will be mailed with the MRN
Harmony Healthcare International, Inc. 109Copyright © 2014 All Rights Reserved
Reconsideration
Include a letter outlining the argument
for payment
The request should clearly explain why
the facility disagrees with the
redetermination
A copy of the MRN, and any other
supportive documentation, should be
sent with the reconsideration request to
the QIC identified in the MRN
Harmony Healthcare International, Inc. 110Copyright © 2014 All Rights Reserved
Reconsideration
Reconsiderations are conducted on-the-
record; and in most cases, the QIC will
send its decision to all parties within 60
days of receipt of the request for
reconsideration
The decision will contain detailed info
on further appeal rights if the decision
is not fully favorable
Harmony Healthcare International, Inc. 111Copyright © 2014 All Rights Reserved
Reconsideration
If the QIC cannot complete its
decision in the applicable
timeframe, it will inform the
appellant of their right to escalate
the case to an ALJ
Harmony Healthcare International, Inc. 112Copyright © 2014 All Rights Reserved
A Successful ALJ Hearing
Harmony Healthcare International, Inc. 113Copyright © 2014 All Rights Reserved
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
The facility must send a notice of the ALJ
hearing request to the QIC on the hearing
request form or in the written request
Harmony Healthcare International, Inc. 114Copyright © 2014 All Rights Reserved
ALJ Overview
A letter to request the ALJ hearing
should simply highlight the most
pertinent reasons justifying
payment
Harmony Healthcare International, Inc. 115Copyright © 2014 All Rights Reserved
ALJ Overview
ALJ hearings are generally held by
video-teleconference (VTC) or by
telephone
If the facility prefers not to have a VTC
or telephone hearing, they may ask for
an in-person hearing, but they must
demonstrate the necessity for an in-
person hearing
Harmony Healthcare International, Inc. 116Copyright © 2014 All Rights Reserved
ALJ Overview
The ALJ will determine whether an in-
person hearing is warranted on a case-by-
case basis
Facilities may also ask the ALJ to make a
decision without a hearing (on-the-
record).
CMS or its contractors may participate in
an ALJ hearing, but they must provide
notice to the ALJ and all parties of the
hearing
Harmony Healthcare International, Inc. 117Copyright © 2014 All Rights Reserved
ALJ Overview
ALJ will generally issue a decision within 90 days of
receipt of the hearing request
The timeframe may be extended for a variety of
reasons including, but not limited to:
The case being escalated from the reconsideration
level
The submission of additional evidence not
included with the hearing request
The request for an in-person hearing
The facility’s failure to send notice of the hearing
request to other parties and
The initiation of discovery if CMS is a party
Harmony Healthcare International, Inc. 118Copyright © 2014 All Rights Reserved
ALJ Overview
If the ALJ does not issue a decision
within the applicable timeframe,
you may ask the ALJ to escalate the
case to the Appeals Council level
Harmony Healthcare International, Inc. 119Copyright © 2014 All Rights Reserved
ALJ
Hearing Preparation
Harmony Healthcare International, Inc. 120Copyright © 2014 All Rights Reserved
ALJ
Office of Medicare Hearings and Appeals (OHMA)
Administrative law judge hearings will not be assigned to
a judge for at least two years
OMHA stopped assigning new hearing requests from
providers as of July 15, 2013
The weekly influx of hearing requests surged from an
average of 1,250 in January 2012 to more than 15,000 in
December 2013
Medicare Appellant Forum to provide updates to OMHA
appellants on the status of OMHA operations
http://www.hhs.gov/omha/omha_medicare_appellant_for
um.html
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 121
ALJ Hearing Preparation
Appeal Process
Discuss and study CMS Guidelines
Discuss type of ALJ hearing (video,
phone, in person) to anticipate the
format
Goals of the Hearing
Inform the Judge of skilled services
Get the claim paid
Harmony Healthcare International, Inc. 122Copyright © 2014 All Rights Reserved
ALJ Hearing Preparation
Team Preparation
Medical record review
Outline of speaking points
Select a point person for the
hearing
Team input
Harmony Healthcare International, Inc. 123Copyright © 2014 All Rights Reserved
ALJ Hearing
Hearing Process
Prepare the facility designated hearing
room for video or phone hearings
Judge’s assistant will initiate the phone
contact (test phone lines and speakers)
Introductions
Statement by facility
Offer to fax any pertinent documents
discussed during the hearing
Harmony Healthcare International, Inc. 124Copyright © 2014 All Rights Reserved
ALJ Hearing
Organize documentation
Keep pertinent notes or forms at your
finger tips
Number the pages for reference
Have the staff that worked with patient
on the call
Speak respectfully, clearly, slowly
Provide a concise summary
Harmony Healthcare International, Inc. 125Copyright © 2014 All Rights Reserved
ALJ Hearing
Be prepared to answer questions prepared
by the Judge
Why did the patient require skilled therapy
when they were hospitalized for a UTI?
Where does the medical record state that
continued therapy services were necessary
after the initial date in question?
Explain why skilled care continued although
the notes indicate the patient did not have an
exacerbation of medical condition?
Harmony Healthcare International, Inc. 126Copyright © 2014 All Rights Reserved
ALJ Hearing
Be prepared to answer questions asked
by the Judge
When did the patient get discharged
from therapy services?
Why do the daily nursing notes state
the patient was ambulating ad lib, yet
physical therapy continued to
provide skilled treatment?
Harmony Healthcare International, Inc. 127Copyright © 2014 All Rights Reserved
Conclusion
Educate, Discuss and Prepare
Don’t Wait for Medicare Medical Review
Communicate to all Staff Medicare Skilled
Care Criteria
Refine Interdisciplinary Management of
Medicare Appeals
Establish and Maintain Peer Review and
External Review of Records to Assure
Insulation of Claims
Harmony Healthcare International, Inc. 128Copyright © 2014 All Rights Reserved
Keys to Success
Provide clinically appropriate care
Document
Medical necessity
Deficits
Outcomes
Meet technical requirements
Review entire medical record
Respond to ADRs timely
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 129
Questions/Answers
Harmony Healthcare International
(978) 887 - 8919
www.Harmony-Healthcare.com
Cmullin@Harmony-Healthcare.com
@KrisMastrangelo
@Harmonyhlthcare
facebook.com/HarmonyHealthcareInternational
H linkedin.com/company/harmony-healthcare
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 130
Copyright © 2014 All Rights Reserved
Register online
http://info.harmony-healthcare.com/harmony2014
or by phone (978) 887-8919 ext. 13
Register Online
Harmony Healthcare International, Inc. 131
Harmony Healthcare International
Have you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM
EVALUATION
or
CASE MIX ANALYSIS
for your Facility?
Perhaps your facility has potential for additional revenue
Assess your facility against key indicators and national norms
Email us at for more information
RUGS@harmony-healthcare.com
Analysis is cost & obligation free
Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 132
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 133

Más contenido relacionado

La actualidad más candente

La actualidad más candente (9)

lesson plan
 lesson plan  lesson plan
lesson plan
 
Atcom booklet & reflective practice
Atcom booklet & reflective practiceAtcom booklet & reflective practice
Atcom booklet & reflective practice
 
Cabin crew interview tips
Cabin crew interview tipsCabin crew interview tips
Cabin crew interview tips
 
Tips in Making Impressive CV
Tips in Making Impressive CVTips in Making Impressive CV
Tips in Making Impressive CV
 
Company Profile Powerpoint Template
Company Profile Powerpoint TemplateCompany Profile Powerpoint Template
Company Profile Powerpoint Template
 
Day 3 session 8 networking
Day 3 session 8 networkingDay 3 session 8 networking
Day 3 session 8 networking
 
Assessment planning and quality assurance, dr. anindya
Assessment planning and quality assurance, dr. anindyaAssessment planning and quality assurance, dr. anindya
Assessment planning and quality assurance, dr. anindya
 
CV Writing Workshop
CV Writing WorkshopCV Writing Workshop
CV Writing Workshop
 
Medical education using standardized/simulated patients
Medical education using standardized/simulated patientsMedical education using standardized/simulated patients
Medical education using standardized/simulated patients
 

Destacado

Bilbo aste nagusia programa 2013
Bilbo aste nagusia programa 2013Bilbo aste nagusia programa 2013
Bilbo aste nagusia programa 2013BASORLEGI
 
Company Profile Professional
Company Profile ProfessionalCompany Profile Professional
Company Profile ProfessionalTonny van Hees
 
Bem estar seja sincero 01-04-12
Bem estar seja sincero 01-04-12Bem estar seja sincero 01-04-12
Bem estar seja sincero 01-04-12Fernanda Caprio
 
Inportancia Virus informaticos
Inportancia Virus informaticosInportancia Virus informaticos
Inportancia Virus informaticosalejanrda
 
Efqm 3c hanna lina werner
Efqm 3c hanna lina wernerEfqm 3c hanna lina werner
Efqm 3c hanna lina wernerpludoni GmbH
 
[WEBINARIO] Gamificación aplicada y cómo incentivar a nuestros clientes con j...
[WEBINARIO] Gamificación aplicada y cómo incentivar a nuestros clientes con j...[WEBINARIO] Gamificación aplicada y cómo incentivar a nuestros clientes con j...
[WEBINARIO] Gamificación aplicada y cómo incentivar a nuestros clientes con j...OM Latam
 
Invitación Evento Presentación The Coach Box
Invitación Evento Presentación The Coach BoxInvitación Evento Presentación The Coach Box
Invitación Evento Presentación The Coach BoxBesatsang
 
Corempresa Nº 11
Corempresa Nº 11Corempresa Nº 11
Corempresa Nº 11corempresa
 
Enterprise Global Messaging
Enterprise Global MessagingEnterprise Global Messaging
Enterprise Global MessagingJonathan Spinney
 
Actarit 18699-02-0-api-manufacturer-suppliers
Actarit 18699-02-0-api-manufacturer-suppliersActarit 18699-02-0-api-manufacturer-suppliers
Actarit 18699-02-0-api-manufacturer-suppliersAcronine-7008-42-6-api
 
Reisebericht Stolze - Mai 2013 SI/HR
Reisebericht Stolze - Mai 2013 SI/HRReisebericht Stolze - Mai 2013 SI/HR
Reisebericht Stolze - Mai 2013 SI/HRherbert1977
 
Catálogo español urnafim 2013
Catálogo español urnafim 2013Catálogo español urnafim 2013
Catálogo español urnafim 2013URNAFIM
 
Creating Creative Events for the Professional Publishers Association Scotland
Creating Creative Events for the Professional Publishers Association ScotlandCreating Creative Events for the Professional Publishers Association Scotland
Creating Creative Events for the Professional Publishers Association ScotlandWilliam Thomson
 
Red and White Shop- The AdVenture Media Case Study
Red and White Shop- The AdVenture Media Case Study   Red and White Shop- The AdVenture Media Case Study
Red and White Shop- The AdVenture Media Case Study Daniel Tawil
 
La prensa como aparato ideológico del Estado
La prensa como aparato ideológico del EstadoLa prensa como aparato ideológico del Estado
La prensa como aparato ideológico del EstadoEva Avila
 
Partes de un computador
Partes de un computadorPartes de un computador
Partes de un computadoralexandra
 

Destacado (20)

Medicare Denied Claims - How the Appeal Letter Can Make or Break You
Medicare Denied Claims - How the Appeal Letter Can Make or Break YouMedicare Denied Claims - How the Appeal Letter Can Make or Break You
Medicare Denied Claims - How the Appeal Letter Can Make or Break You
 
CSCC Appeal Letter
CSCC Appeal LetterCSCC Appeal Letter
CSCC Appeal Letter
 
Bilbo aste nagusia programa 2013
Bilbo aste nagusia programa 2013Bilbo aste nagusia programa 2013
Bilbo aste nagusia programa 2013
 
Company Profile Professional
Company Profile ProfessionalCompany Profile Professional
Company Profile Professional
 
Día internacional del libro
Día internacional del libroDía internacional del libro
Día internacional del libro
 
Bem estar seja sincero 01-04-12
Bem estar seja sincero 01-04-12Bem estar seja sincero 01-04-12
Bem estar seja sincero 01-04-12
 
Inportancia Virus informaticos
Inportancia Virus informaticosInportancia Virus informaticos
Inportancia Virus informaticos
 
Efqm 3c hanna lina werner
Efqm 3c hanna lina wernerEfqm 3c hanna lina werner
Efqm 3c hanna lina werner
 
[WEBINARIO] Gamificación aplicada y cómo incentivar a nuestros clientes con j...
[WEBINARIO] Gamificación aplicada y cómo incentivar a nuestros clientes con j...[WEBINARIO] Gamificación aplicada y cómo incentivar a nuestros clientes con j...
[WEBINARIO] Gamificación aplicada y cómo incentivar a nuestros clientes con j...
 
Invitación Evento Presentación The Coach Box
Invitación Evento Presentación The Coach BoxInvitación Evento Presentación The Coach Box
Invitación Evento Presentación The Coach Box
 
Corempresa Nº 11
Corempresa Nº 11Corempresa Nº 11
Corempresa Nº 11
 
Enterprise Global Messaging
Enterprise Global MessagingEnterprise Global Messaging
Enterprise Global Messaging
 
Actarit 18699-02-0-api-manufacturer-suppliers
Actarit 18699-02-0-api-manufacturer-suppliersActarit 18699-02-0-api-manufacturer-suppliers
Actarit 18699-02-0-api-manufacturer-suppliers
 
Reisebericht Stolze - Mai 2013 SI/HR
Reisebericht Stolze - Mai 2013 SI/HRReisebericht Stolze - Mai 2013 SI/HR
Reisebericht Stolze - Mai 2013 SI/HR
 
Bernardo houssay (1)
Bernardo houssay (1)Bernardo houssay (1)
Bernardo houssay (1)
 
Catálogo español urnafim 2013
Catálogo español urnafim 2013Catálogo español urnafim 2013
Catálogo español urnafim 2013
 
Creating Creative Events for the Professional Publishers Association Scotland
Creating Creative Events for the Professional Publishers Association ScotlandCreating Creative Events for the Professional Publishers Association Scotland
Creating Creative Events for the Professional Publishers Association Scotland
 
Red and White Shop- The AdVenture Media Case Study
Red and White Shop- The AdVenture Media Case Study   Red and White Shop- The AdVenture Media Case Study
Red and White Shop- The AdVenture Media Case Study
 
La prensa como aparato ideológico del Estado
La prensa como aparato ideológico del EstadoLa prensa como aparato ideológico del Estado
La prensa como aparato ideológico del Estado
 
Partes de un computador
Partes de un computadorPartes de un computador
Partes de un computador
 

Similar a How to Review Medicare Appeals in the SNF

Medicare Documentation for the Rehabilitation Patient: Evidence of Progress
Medicare Documentation for the Rehabilitation Patient: Evidence of ProgressMedicare Documentation for the Rehabilitation Patient: Evidence of Progress
Medicare Documentation for the Rehabilitation Patient: Evidence of ProgressHarmony Healthcare International (HHI)
 
What You Will Learn •  Long-term care is heavily regulated because.docx
What You Will Learn •  Long-term care is heavily regulated because.docxWhat You Will Learn •  Long-term care is heavily regulated because.docx
What You Will Learn •  Long-term care is heavily regulated because.docxeubanksnefen
 
WEBINAR: Performance Improvement for Children’s Hospitals – Key Steps in Deve...
WEBINAR: Performance Improvement for Children’s Hospitals – Key Steps in Deve...WEBINAR: Performance Improvement for Children’s Hospitals – Key Steps in Deve...
WEBINAR: Performance Improvement for Children’s Hospitals – Key Steps in Deve...Huron Consulting Group
 
Jd Revised Undestanding Insurance Eliigibilityprocess Iii
Jd Revised Undestanding Insurance Eliigibilityprocess IiiJd Revised Undestanding Insurance Eliigibilityprocess Iii
Jd Revised Undestanding Insurance Eliigibilityprocess Iiijdesir8472
 

Similar a How to Review Medicare Appeals in the SNF (20)

RAC Audit Strategic Road Map for Leaders
RAC Audit Strategic Road Map for LeadersRAC Audit Strategic Road Map for Leaders
RAC Audit Strategic Road Map for Leaders
 
ADR Process for the SNF: Medicare Part B Claims
ADR Process for the SNF: Medicare Part B ClaimsADR Process for the SNF: Medicare Part B Claims
ADR Process for the SNF: Medicare Part B Claims
 
Medicare Documentation for the Rehabilitation Patient: Evidence of Progress
Medicare Documentation for the Rehabilitation Patient: Evidence of ProgressMedicare Documentation for the Rehabilitation Patient: Evidence of Progress
Medicare Documentation for the Rehabilitation Patient: Evidence of Progress
 
Unusual Weather We Are Having: The Medicare Audit Climate
Unusual Weather We Are Having: The Medicare Audit ClimateUnusual Weather We Are Having: The Medicare Audit Climate
Unusual Weather We Are Having: The Medicare Audit Climate
 
Nursing Documentation: Do Your Medical Records Support Skilled Care?
Nursing Documentation: Do Your Medical Records Support Skilled Care?Nursing Documentation: Do Your Medical Records Support Skilled Care?
Nursing Documentation: Do Your Medical Records Support Skilled Care?
 
The Cost of Non-Compliance: Is it in Your Budget?
The Cost of Non-Compliance: Is it in Your Budget?The Cost of Non-Compliance: Is it in Your Budget?
The Cost of Non-Compliance: Is it in Your Budget?
 
Medicare Denied Claims: How the Appeal Letter Can Make or Break You
Medicare Denied Claims: How the Appeal Letter Can Make or Break YouMedicare Denied Claims: How the Appeal Letter Can Make or Break You
Medicare Denied Claims: How the Appeal Letter Can Make or Break You
 
ABCs of Care Planning
ABCs of Care PlanningABCs of Care Planning
ABCs of Care Planning
 
Medicare Madness 2014: What You Need to Know
Medicare Madness 2014: What You Need to KnowMedicare Madness 2014: What You Need to Know
Medicare Madness 2014: What You Need to Know
 
Are You Ready for the SNF PEPPER?
Are You Ready for the SNF PEPPER?Are You Ready for the SNF PEPPER?
Are You Ready for the SNF PEPPER?
 
What You Will Learn •  Long-term care is heavily regulated because.docx
What You Will Learn •  Long-term care is heavily regulated because.docxWhat You Will Learn •  Long-term care is heavily regulated because.docx
What You Will Learn •  Long-term care is heavily regulated because.docx
 
Top Ten Missed Opportunities in the Skilled Nursing Facility
Top Ten Missed Opportunities in the Skilled Nursing FacilityTop Ten Missed Opportunities in the Skilled Nursing Facility
Top Ten Missed Opportunities in the Skilled Nursing Facility
 
Denials Management from ADR to ALJ
Denials Management from ADR to ALJDenials Management from ADR to ALJ
Denials Management from ADR to ALJ
 
Top Ten Tips for a Successful ALJ Hearing
Top Ten Tips for a Successful ALJ HearingTop Ten Tips for a Successful ALJ Hearing
Top Ten Tips for a Successful ALJ Hearing
 
WEBINAR: Performance Improvement for Children’s Hospitals – Key Steps in Deve...
WEBINAR: Performance Improvement for Children’s Hospitals – Key Steps in Deve...WEBINAR: Performance Improvement for Children’s Hospitals – Key Steps in Deve...
WEBINAR: Performance Improvement for Children’s Hospitals – Key Steps in Deve...
 
FY 2014 Final Rule and MDS 3.0 Updates
FY 2014 Final Rule and MDS 3.0 UpdatesFY 2014 Final Rule and MDS 3.0 Updates
FY 2014 Final Rule and MDS 3.0 Updates
 
Jd Revised Undestanding Insurance Eliigibilityprocess Iii
Jd Revised Undestanding Insurance Eliigibilityprocess IiiJd Revised Undestanding Insurance Eliigibilityprocess Iii
Jd Revised Undestanding Insurance Eliigibilityprocess Iii
 
Patient right
Patient rightPatient right
Patient right
 
Patient right
Patient rightPatient right
Patient right
 
Patient right
Patient rightPatient right
Patient right
 

Más de Harmony Healthcare International (HHI)

SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual UpdatesSNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual UpdatesHarmony Healthcare International (HHI)
 
Why, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
Why, How, What: Compliance, Operations & Reimbursment - The Circle of SafetyWhy, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
Why, How, What: Compliance, Operations & Reimbursment - The Circle of SafetyHarmony Healthcare International (HHI)
 
Medicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
Medicare PPS Schedule: Managing Early, Late, and Missed PPS AssessmentsMedicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
Medicare PPS Schedule: Managing Early, Late, and Missed PPS AssessmentsHarmony Healthcare International (HHI)
 

Más de Harmony Healthcare International (HHI) (20)

SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual UpdatesSNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
SNF Guide To FY2015 PPS Final Rule & October 1st RAI User's Manual Updates
 
Interpreting Your 2014 SNF PEPPER
Interpreting Your 2014 SNF PEPPERInterpreting Your 2014 SNF PEPPER
Interpreting Your 2014 SNF PEPPER
 
Incorporating PEPPER Into Your SNF Compliance Program
Incorporating PEPPER Into Your SNF Compliance ProgramIncorporating PEPPER Into Your SNF Compliance Program
Incorporating PEPPER Into Your SNF Compliance Program
 
How Safe is Your Patient Data?
How Safe is Your Patient Data?How Safe is Your Patient Data?
How Safe is Your Patient Data?
 
Steps Towards a Successful Regulatory Survey
Steps Towards a Successful Regulatory SurveySteps Towards a Successful Regulatory Survey
Steps Towards a Successful Regulatory Survey
 
Why, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
Why, How, What: Compliance, Operations & Reimbursment - The Circle of SafetyWhy, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
Why, How, What: Compliance, Operations & Reimbursment - The Circle of Safety
 
Thinking Out of the Box: Treatment Planning Outside the Gym
Thinking Out of the Box: Treatment Planning Outside the GymThinking Out of the Box: Treatment Planning Outside the Gym
Thinking Out of the Box: Treatment Planning Outside the Gym
 
Top 5 Ways to Prevent Falls
Top 5 Ways to Prevent FallsTop 5 Ways to Prevent Falls
Top 5 Ways to Prevent Falls
 
The RAI Process: CAAs, Care Planning and Beyond
The RAI Process: CAAs, Care Planning and BeyondThe RAI Process: CAAs, Care Planning and Beyond
The RAI Process: CAAs, Care Planning and Beyond
 
Quality Assurance Performance Improvement: 12 Steps to Excellence!
Quality Assurance Performance Improvement: 12 Steps to Excellence!Quality Assurance Performance Improvement: 12 Steps to Excellence!
Quality Assurance Performance Improvement: 12 Steps to Excellence!
 
OM(I)G! New York Medicaid Case Mix Audit Success
OM(I)G! New York Medicaid Case Mix Audit SuccessOM(I)G! New York Medicaid Case Mix Audit Success
OM(I)G! New York Medicaid Case Mix Audit Success
 
Medicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
Medicare PPS Schedule: Managing Early, Late, and Missed PPS AssessmentsMedicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
Medicare PPS Schedule: Managing Early, Late, and Missed PPS Assessments
 
Medicare Part B Program Development in the Age of Compliance
Medicare Part B Program Development in the Age of ComplianceMedicare Part B Program Development in the Age of Compliance
Medicare Part B Program Development in the Age of Compliance
 
Measure Up with Standardized Assessments
Measure Up with Standardized AssessmentsMeasure Up with Standardized Assessments
Measure Up with Standardized Assessments
 
MDS Interviews: What Does "Sock,Bed,Blue" Mean to You?
MDS Interviews: What Does "Sock,Bed,Blue" Mean to You?MDS Interviews: What Does "Sock,Bed,Blue" Mean to You?
MDS Interviews: What Does "Sock,Bed,Blue" Mean to You?
 
MDS 3.0: A Guide to Coding Accuracy
MDS 3.0: A Guide to Coding AccuracyMDS 3.0: A Guide to Coding Accuracy
MDS 3.0: A Guide to Coding Accuracy
 
Management of the Non-Traditional Rehabilitation Patient
Management of the Non-Traditional Rehabilitation PatientManagement of the Non-Traditional Rehabilitation Patient
Management of the Non-Traditional Rehabilitation Patient
 
M is for Miscoding
M is for MiscodingM is for Miscoding
M is for Miscoding
 
Is Antipsychotic Medication Reduction Making You Crazy?
Is Antipsychotic Medication Reduction Making You Crazy?Is Antipsychotic Medication Reduction Making You Crazy?
Is Antipsychotic Medication Reduction Making You Crazy?
 
Hospital Readmission Roullette
Hospital Readmission RoulletteHospital Readmission Roullette
Hospital Readmission Roullette
 

Último

World Autism Awareness day describin.ppt
World Autism Awareness day describin.pptWorld Autism Awareness day describin.ppt
World Autism Awareness day describin.pptShifaSikri3
 
NABH Onsite assessment Questions for all department pptx
NABH Onsite assessment Questions for all department pptxNABH Onsite assessment Questions for all department pptx
NABH Onsite assessment Questions for all department pptxGODWIN SUJIN
 
Presentation on COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
Presentation on  COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSINGPresentation on  COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
Presentation on COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSINGKREDASONBANGALORE
 
Disability & Inclusion Training for health professionals.pptx
Disability & Inclusion Training for health professionals.pptxDisability & Inclusion Training for health professionals.pptx
Disability & Inclusion Training for health professionals.pptxtilahun36
 
Dr. David Greene's Guide to Healing: Unleashing PRP's Power on Blood Stem Cells
Dr. David Greene's Guide to Healing: Unleashing PRP's Power on Blood Stem CellsDr. David Greene's Guide to Healing: Unleashing PRP's Power on Blood Stem Cells
Dr. David Greene's Guide to Healing: Unleashing PRP's Power on Blood Stem CellsDr. David Greene Arizona
 
Determining Prognosis in Cancer and Non-Cancer Diagnoses
Determining Prognosis in Cancer and Non-Cancer DiagnosesDetermining Prognosis in Cancer and Non-Cancer Diagnoses
Determining Prognosis in Cancer and Non-Cancer DiagnosesVITASAuthor
 
MAGNETIC RESONANCE IMAGING QUESTION AND ANSWER 3 MARKS.pdf
MAGNETIC RESONANCE IMAGING QUESTION AND ANSWER 3 MARKS.pdfMAGNETIC RESONANCE IMAGING QUESTION AND ANSWER 3 MARKS.pdf
MAGNETIC RESONANCE IMAGING QUESTION AND ANSWER 3 MARKS.pdfGanesan Yogananthem
 
Unit 4- Therapuetic communication.pptx coomunication, process recording
Unit 4- Therapuetic communication.pptx coomunication, process recordingUnit 4- Therapuetic communication.pptx coomunication, process recording
Unit 4- Therapuetic communication.pptx coomunication, process recordingS.DHIVYALAKSHMI
 
QUALITY ASSURANCE .. quality assurance and quality control.
QUALITY ASSURANCE .. quality assurance and quality control.QUALITY ASSURANCE .. quality assurance and quality control.
QUALITY ASSURANCE .. quality assurance and quality control.Talal Albudayri
 
Introduction-to-Artificial-Intelligence-in-Public-Health.pptx
Introduction-to-Artificial-Intelligence-in-Public-Health.pptxIntroduction-to-Artificial-Intelligence-in-Public-Health.pptx
Introduction-to-Artificial-Intelligence-in-Public-Health.pptxspmdoc
 
Sensitive analysis - Unit I (Computer aided drug development.pptx
Sensitive analysis - Unit I (Computer aided drug development.pptxSensitive analysis - Unit I (Computer aided drug development.pptx
Sensitive analysis - Unit I (Computer aided drug development.pptxsneha_pharmacist
 
Histrionic, Narcissistic & Avoidance Personality Disorder | Psychiatric Nursi...
Histrionic, Narcissistic & Avoidance Personality Disorder | Psychiatric Nursi...Histrionic, Narcissistic & Avoidance Personality Disorder | Psychiatric Nursi...
Histrionic, Narcissistic & Avoidance Personality Disorder | Psychiatric Nursi...Juhin J
 
TEST BANK For Neonatal and Pediatric Respiratory Care, 6th Edition by Brian K...
TEST BANK For Neonatal and Pediatric Respiratory Care, 6th Edition by Brian K...TEST BANK For Neonatal and Pediatric Respiratory Care, 6th Edition by Brian K...
TEST BANK For Neonatal and Pediatric Respiratory Care, 6th Edition by Brian K...mwangimwangi222
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxPamela McKinney
 
ECG analysis on normal sinus rhythm and atrial arrhythmias.pptx
ECG analysis on  normal sinus rhythm and atrial arrhythmias.pptxECG analysis on  normal sinus rhythm and atrial arrhythmias.pptx
ECG analysis on normal sinus rhythm and atrial arrhythmias.pptxcvkrishnapriya575
 
Handing Taking Over by using SBAR. pptx
Handing Taking Over by using SBAR.  pptxHanding Taking Over by using SBAR.  pptx
Handing Taking Over by using SBAR. pptxHussain278181
 

Último (20)

World Autism Awareness day describin.ppt
World Autism Awareness day describin.pptWorld Autism Awareness day describin.ppt
World Autism Awareness day describin.ppt
 
NABH Onsite assessment Questions for all department pptx
NABH Onsite assessment Questions for all department pptxNABH Onsite assessment Questions for all department pptx
NABH Onsite assessment Questions for all department pptx
 
Presentation on COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
Presentation on  COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSINGPresentation on  COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
Presentation on COUNSELING. 1ST YEAR GNM ,COMMUNITY HEALTH NURSING
 
Disability & Inclusion Training for health professionals.pptx
Disability & Inclusion Training for health professionals.pptxDisability & Inclusion Training for health professionals.pptx
Disability & Inclusion Training for health professionals.pptx
 
Dr. David Greene's Guide to Healing: Unleashing PRP's Power on Blood Stem Cells
Dr. David Greene's Guide to Healing: Unleashing PRP's Power on Blood Stem CellsDr. David Greene's Guide to Healing: Unleashing PRP's Power on Blood Stem Cells
Dr. David Greene's Guide to Healing: Unleashing PRP's Power on Blood Stem Cells
 
Determining Prognosis in Cancer and Non-Cancer Diagnoses
Determining Prognosis in Cancer and Non-Cancer DiagnosesDetermining Prognosis in Cancer and Non-Cancer Diagnoses
Determining Prognosis in Cancer and Non-Cancer Diagnoses
 
MAGNETIC RESONANCE IMAGING QUESTION AND ANSWER 3 MARKS.pdf
MAGNETIC RESONANCE IMAGING QUESTION AND ANSWER 3 MARKS.pdfMAGNETIC RESONANCE IMAGING QUESTION AND ANSWER 3 MARKS.pdf
MAGNETIC RESONANCE IMAGING QUESTION AND ANSWER 3 MARKS.pdf
 
Pediatric General: Different Kinds of Language
Pediatric General: Different Kinds of LanguagePediatric General: Different Kinds of Language
Pediatric General: Different Kinds of Language
 
Unit 4- Therapuetic communication.pptx coomunication, process recording
Unit 4- Therapuetic communication.pptx coomunication, process recordingUnit 4- Therapuetic communication.pptx coomunication, process recording
Unit 4- Therapuetic communication.pptx coomunication, process recording
 
Pediatric Language: Fast Facts of Bilingualism
Pediatric Language: Fast Facts of BilingualismPediatric Language: Fast Facts of Bilingualism
Pediatric Language: Fast Facts of Bilingualism
 
QUALITY ASSURANCE .. quality assurance and quality control.
QUALITY ASSURANCE .. quality assurance and quality control.QUALITY ASSURANCE .. quality assurance and quality control.
QUALITY ASSURANCE .. quality assurance and quality control.
 
SCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATIONSCOPE OF CRITICAL CARE ORGANIZATION
SCOPE OF CRITICAL CARE ORGANIZATION
 
Introduction-to-Artificial-Intelligence-in-Public-Health.pptx
Introduction-to-Artificial-Intelligence-in-Public-Health.pptxIntroduction-to-Artificial-Intelligence-in-Public-Health.pptx
Introduction-to-Artificial-Intelligence-in-Public-Health.pptx
 
Pediatric Social Language: Instead of "I Don't Know"
Pediatric Social Language: Instead of "I Don't Know"Pediatric Social Language: Instead of "I Don't Know"
Pediatric Social Language: Instead of "I Don't Know"
 
Sensitive analysis - Unit I (Computer aided drug development.pptx
Sensitive analysis - Unit I (Computer aided drug development.pptxSensitive analysis - Unit I (Computer aided drug development.pptx
Sensitive analysis - Unit I (Computer aided drug development.pptx
 
Histrionic, Narcissistic & Avoidance Personality Disorder | Psychiatric Nursi...
Histrionic, Narcissistic & Avoidance Personality Disorder | Psychiatric Nursi...Histrionic, Narcissistic & Avoidance Personality Disorder | Psychiatric Nursi...
Histrionic, Narcissistic & Avoidance Personality Disorder | Psychiatric Nursi...
 
TEST BANK For Neonatal and Pediatric Respiratory Care, 6th Edition by Brian K...
TEST BANK For Neonatal and Pediatric Respiratory Care, 6th Edition by Brian K...TEST BANK For Neonatal and Pediatric Respiratory Care, 6th Edition by Brian K...
TEST BANK For Neonatal and Pediatric Respiratory Care, 6th Edition by Brian K...
 
Health literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptxHealth literacies in marginalised communities LILAC 24.pptx
Health literacies in marginalised communities LILAC 24.pptx
 
ECG analysis on normal sinus rhythm and atrial arrhythmias.pptx
ECG analysis on  normal sinus rhythm and atrial arrhythmias.pptxECG analysis on  normal sinus rhythm and atrial arrhythmias.pptx
ECG analysis on normal sinus rhythm and atrial arrhythmias.pptx
 
Handing Taking Over by using SBAR. pptx
Handing Taking Over by using SBAR.  pptxHanding Taking Over by using SBAR.  pptx
Handing Taking Over by using SBAR. pptx
 

How to Review Medicare Appeals in the SNF

  • 1. How to Review the SNF Appeal Process HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Carrie Mullin OTR/L, RAC-CT Claims Review Specialist
  • 2. Harmony Healthcare International, Inc. Speaker Bio (Caroline Mullin) Director of Denial Services for Harmony Healthcare International, Inc. and Corporate Consultant for HHI since 2008 MS OTR/L, RAC-CT Education: Masters of Science in Occupational Therapy from Spalding University in Louisville, KY Continuing Education in Contracture and Geriatric Therapeutic Exercise Courses Experience: Senior Occupational Therapist and Director of Rehabilitation Services at Episcopal Senior Life Communities in Rochester, NY Expert in Denials, Appeal letters, and prepping facilities for ALJ hearings Copyright © 2014 All Rights Reserved 2
  • 3. Objectives Learner will be able to summarize SNF Medicare qualifiers Learner will be able to articulate Audit Triggers Learner will be able to Summarize Medical Record Preparedness Learner will be able to Summarize the ADR and appeal process Learner will be able to articulate strategies for participation in ALJ Hearings Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 3
  • 4. Documenting Medicare Skilled Coverage Requirements DEFENSE!! Copyright © 2014 All Rights Reserved 4Harmony Healthcare International, Inc. The KEY to Preventing Denials
  • 5. 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.” 5Harmony Healthcare International, Inc.
  • 6. Prevention The key to preventing denials is documentation of skilled services provided The key to documenting skilled services provided is understanding the Medicare requirements for coverage Copyright © 2014 All Rights Reserved 6Harmony Healthcare International, Inc.
  • 7. The Importance of Documentation The key to ensuring accurate reimbursement for services provided is understanding skilled coverage requirements Copyright © 2014 All Rights Reserved 7Harmony Healthcare International, Inc.
  • 8. Medicare Manual Source Document Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (Rev. 175, 12-06-13) Effective 1/7/14 Copyright © 2014 All Rights Reserved 8Harmony Healthcare International, Inc.
  • 9. Medicare Coverage/Skilled Care Provided on a “daily” basis: Skilled nursing (or combination of nursing and rehabilitation) must be seven days per week Skilled restorative nursing must be at least six days per week Rehabilitation (PT, OT and/or SLP) must be at least five days per week An isolated break of “a day or two” is allowable Copyright © 2014 All Rights Reserved 9Harmony Healthcare International, Inc.
  • 10. Chapter 8 Medicare Manual (2014) Rehabilitation Daily Single type of skilled rehabilitation every day, or by furnishing various types of skilled services on different days that collectively add up to “daily” skilled services. “Arbitrarily staggering the timing of various therapy modalities though the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.” To meet this requirement, the patient must actually need skilled rehabilitation services to be furnished on each of the days that the facility makes such services available “ Copyright © 2014 All Rights Reserved 10Harmony Healthcare International, Inc.
  • 11. What is Skilled Care? Nature of service requires the skills of a licensed person (e.g. technical or professional personnel) Skilled services are provided directly by or under general supervision of a licensed nurse or therapist to assure the safety of the patient and to achieve the medically desired result Diagnosis and prognosis do not determine what is skilled care – it is the care of the patient that is the deciding factor Copyright © 2014 All Rights Reserved 11Harmony Healthcare International, Inc.
  • 12. “Practical Matter” Criterion “As a practical matter, considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility” Copyright © 2014 All Rights Reserved 12Harmony Healthcare International, Inc.
  • 13. “Practical Matter” Criterion 1. Outpatient services are not available in the area where the individual lives 2.Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective than placement in the skilled nursing facility Copyright © 2014 All Rights Reserved 13Harmony Healthcare International, Inc.
  • 14. “Practical Matter” Criterion 3. The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/patient to reside there safely 4. If the use of alternative services would adversely affect the patient/patient’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis Copyright © 2014 All Rights Reserved 14Harmony Healthcare International, Inc.
  • 15. Basic Medicare Requirements If any one of these three factors is not supported by the documentation in the patient’s record, the SNF stay, even though it might include the delivery of daily skilled services, will not be covered. Copyright © 2014 All Rights Reserved 15Harmony Healthcare International, Inc.
  • 16. RUG-IV Resource Utilization Groups Each MDS qualifies for multiple RUGs, and the software automatically chooses the highest reimbursement rate Rehabilitation Intensity, Diagnoses, Nursing Services, and ADLs all contribute Documentation must support all coding on the MDS 3.0 assessment Copyright © 2014 All Rights Reserved 16Harmony Healthcare International, Inc.
  • 17. Presumption of Coverage Medicare beneficiaries who are correctly assigned to one of the upper 52 RUG-IV groups on the initial 5-Day, Medicare required assessment are automatically classified as meeting the SNF level of care definition up to and including the assessment reference date on the 5-day Medicare- required assessment Only applies when admitted from Acute Care Hospital (Not Swingbed or another SNF) Copyright © 2014 All Rights Reserved 17Harmony Healthcare International, Inc.
  • 18. Presumption of Coverage This presumption recognizes the strong likelihood that beneficiaries assigned to one of the upper 52 RUG-IV groups during the immediate post-hospital period require a covered level of care, which would be less likely for those beneficiaries assigned to one of the lower 14 RUG-IV groups Copyright © 2014 All Rights Reserved 18Harmony Healthcare International, Inc.
  • 19. Presumption of Coverage This administrative presumption policy does not supersede the SNF’s responsibility to ensure that its decisions relating to level of care are appropriate and timely, including a review to confirm that the services prompting the beneficiary’s assignment to one of the upper 52 RUG-IV groups Copyright © 2014 All Rights Reserved 19Harmony Healthcare International, Inc.
  • 20. Totality While it is true that dialysis is one of the discrete indicators for assignment to a RUG within the Special Care Low category – a category to which the level of care presumption applies for a short period of time at the start of a SNF stay – it is the totality of items and services included within a given RUG, not any one specific coded service, that actually serves to justify the presumption Copyright © 2014 All Rights Reserved 20Harmony Healthcare International, Inc.
  • 21. What is Skilled Care ? Direct Skilled Nursing Services Management and Evaluation of a Care Plan Observation and Assessment Teaching and Training Skilled Rehabilitation Copyright © 2014 All Rights Reserved 21Harmony Healthcare International, Inc.
  • 22. What is Skilled Care? Nursing Anchors the Skill Need to remain in a SNF Medical Complexity Supports Non-Therapy RUG Increased potential Lower 14 and reviews with October 1st Changes Copyright © 2014 All Rights Reserved 22Harmony Healthcare International, Inc.
  • 23. Skilled Services Categories: Nursing Inherent Complexity Inherent Complexity – Direct skilled nursing services including: IV feeding IV meds Suctioning Tracheostomy Care Ventilator support Ulcers Copyright © 2014 All Rights Reserved 23Harmony Healthcare International, Inc.
  • 24. Skilled Services Categories: Nursing 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 Copyright © 2014 All Rights Reserved 24Harmony Healthcare International, Inc.
  • 25. Observation and Assessment Skilled services when the likelihood of change in a patient’s condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures, until the patient’s condition is essentially stabilized. Reasonable potential for a future complication or acute episode sufficient to justify the need for continued skilled observation and assessment. Copyright © 2014 All Rights Reserved 25Harmony Healthcare International, Inc.
  • 26. Observation and Assessment Example (from Chapter 8 of the Medicare Benefit Policy Manual): A patient has been hospitalized following a heart attack, and following treatment but before mobilization, is transferred to the SNF Copyright © 2014 All Rights Reserved 26Harmony Healthcare International, Inc.
  • 27. Observation and Assessment Example (continued): Because it is unknown whether exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated, until the patient’s treatment regimen is essentially stabilized Copyright © 2014 All Rights Reserved 27Harmony Healthcare International, Inc.
  • 28. Observation and Assessment The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the stabilization of the patient's medical condition and safety (Effective 1/2014). Copyright © 2014 All Rights Reserved 28Harmony Healthcare International, Inc.
  • 29. Observation and Assessment KEY POINT: If a patient was admitted for skilled observation but did not develop a further acute episode or other complications, the skilled observation services still are covered so long as there was a reasonable probability for such a complication or further acute episode Copyright © 2014 All Rights Reserved 29Harmony Healthcare International, Inc.
  • 30. Observation and Assessment Fever Dehydration Septicemia Pneumonia Nutritional Risk Chemotherapy Weight loss Blood sugar control Impaired cognition Severe Mood and Behavior conditions Copyright © 2014 All Rights Reserved 30Harmony Healthcare International, Inc.
  • 32. 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 Copyright © 2014 All Rights Reserved 32Harmony Healthcare International, Inc.
  • 33. 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 Copyright © 2014 All Rights Reserved 33Harmony Healthcare International, Inc.
  • 34. Copyright © 2014 All Rights Reserved 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 of clinical practice. Expectation of improvement of restorative potential in a reasonable and predictable amount of time…or… Establishment of a safe and effective maintenance program. 34Harmony Healthcare International, Inc.
  • 35. Copyright © 2014 All Rights Reserved Medicare Benefit Policy The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist. 35Harmony Healthcare International, Inc.
  • 36. Harmony Healthcare International, Inc. 36 Maintenance Therapy Maintenance Therapy. The repetitive services required to maintain function sometimes involve the use of complex and sophisticated therapy procedures and consequently, the judgment and skill of a physical therapist might be required for the safe and effective rendition of such services (see §214.1.B). 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 (Effective 1/2014). Copyright © 2014 All Rights Reserved 36Harmony Healthcare International, Inc.
  • 37. Maintenance Therapy Therapy services in connection with a maintenance program 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) If all other requirements for coverage under the SNF benefit are met, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program. Copyright © 2014 All Rights Reserved 37Harmony Healthcare International, Inc.
  • 38. Jimmo v. Sebelius The Jimmo v. Sebelius lawsuit was brought on behalf of a nationwide class of Medicare beneficiaries by six individual Medicare beneficiaries and seven national organizations representing people with chronic conditions The Jimmo v. Sebelius case challenged Medicare's use of an "Improvement Standard" to make coverage determinations Copyright © 2014 All Rights Reserved 38Harmony Healthcare International, Inc.
  • 39. Jimmo v. Sebelius On January 24, 2013, a settlement was approved by the federal district court in Vermont in the case of Jimmo v. Sebelius regarding the "Improvement Standard" Addresses the ability to terminate or deny coverage to beneficiaries who are not improving for Medicare Part A and Part B Copyright © 2014 All Rights Reserved 39Harmony Healthcare International, Inc.
  • 40. Jimmo v. Sebelius Expands Medicare Part A and Part B coverage to include the rendering of skilled nursing and therapy services necessary to maintain a person's condition and is not dependent on whether the Medicare beneficiary “will improve”. CMS Fact Sheet States this is simply a clarification Copyright © 2014 All Rights Reserved 40Harmony Healthcare International, Inc.
  • 41. Jimmo v. Sebelius The judgment indicates that as long as a patient requires skills of a therapist or a nurse a patient would meet skilled coverage criteria despite not making functional gains Documentation must support the need for skilled therapy intervention Copyright © 2014 All Rights Reserved 41Harmony Healthcare International, Inc.
  • 42. Skills of a Therapist or a Nurse 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 Copyright © 2014 All Rights Reserved 42Harmony Healthcare International, Inc.
  • 43. Skilled Nursing Documentation What To Consider Including Patient is at high risk for … Skilled assessment of … Daily skilled monitoring of … Potential for recurrence of … Potential for the following complications… There is a likelihood of change related to… The medical regimen is not essentially stabilized as evidenced by… Copyright © 2014 All Rights Reserved 43Harmony Healthcare International, Inc.
  • 44. Skilled Nursing Documentation What To Consider Including Patient continues to require daily skilled rehab for … Observation and assessment for potential complications related to … Potential for medical complications related to the diagnosis of … Plan of care is being monitored to promote recovery and ensure medical safety related to … The patient requires daily skilled management and evaluation of the plan of care related to … Copyright © 2014 All Rights Reserved 44Harmony Healthcare International, Inc.
  • 45. Skilled Nursing Documentation What To Consider Including Skilled neurological assessment resulted in… Daily skilled monitoring for signs and symptoms of exacerbation of _____ secondary to _______ Patient is high risk for ______ secondary to _______ Medications adjusted to _____________, ongoing skilled assessment of regimen to promote recovery and ensure medical safety Patient continues to require daily skilled nursing as his treatment regimen is not essentially stabilized and there is a potential for recurrence of ________ Copyright © 2014 All Rights Reserved 45Harmony Healthcare International, Inc.
  • 46. Non-Supportive Nursing Documentation Plateau in progress Voiced no complaints Patient requires custodial care Patient requires intermittent care Patient is unable to follow directions Patient requires intermittent services Patient has poor rehabilitation potential Patients medical treatment is essentially stabilized Refuses to participate in therapy (instead give the reason the patient is unable) Condition stable Slept well/family into visit Copyright © 2014 All Rights Reserved 46Harmony Healthcare International, Inc.
  • 47. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 47Harmony Healthcare International, Inc. 47 Recovery Audit Contractors
  • 48. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 48Harmony Healthcare International, Inc. 48 Recovery Audit Contractors The Recovery Auditors Program Mission The Recovery Auditor detect and correct 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.
  • 49. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 49Harmony Healthcare International, Inc. 49 Recovery Audit Contractors If you bill fee-for-service programs, your claims will be subject to review by the Recovery Auditors.
  • 50. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 50Harmony Healthcare International, Inc. 50 Recovery Audit Contractors 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
  • 51. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 51Harmony Healthcare International, Inc. 51 Recovery Audit Contractors The appeal process for Recovery Audit denials is the same as the appeal process for Carrier/FI/MAC denials Do not confuse the “Recovery Audit Programs’ Discussion Period” with the Appeals process If you disagree with the Recovery Auditor’s determination: Do not stop with sending a discussion letter File an appeal before the 120th day after the Demand letter.
  • 52. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 52Harmony Healthcare International, Inc. 52 Recovery Audit Contractors Recovery Auditors will offer an opportunity for the provider to discuss the improper payment determination with the Recovery Auditors (this is outside the normal appeal process)
  • 53. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 53Harmony Healthcare International, Inc. 53 Appeal Determinations
  • 54. 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 54
  • 55. 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 55
  • 56. 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 56
  • 57. Denial Reasons Reasonable 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 57
  • 58. 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. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 58
  • 59. Denial Reasons Deconditioning 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 59
  • 60. Denial Reasons Restorative 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 60Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  • 61. Denial Reasons Custodial Level of Care 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 and that needs were custodial in nature and could have been met with restorative nursing, family member, or nursing assistant 61Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  • 62. Denial Reasons Prior 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 62
  • 63. Denial Reasons Rehab 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 63
  • 64. 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 64
  • 65. 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 65
  • 66. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 66 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
  • 67. 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 67Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  • 68. 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 68
  • 69. Denial Reasons Inpatient 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 69Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  • 70. Denial Reasons Medical 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 70Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  • 71. 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 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 71
  • 72. Appeal Process Harmony Healthcare International, Inc. 72Copyright © 2014 All Rights Reserved
  • 73. Appeal Rights Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 73
  • 74. Appeal Rights Right to Appeal: If the Beneficiaries is the only one with the right to appeal given specific situations, provider must obtain transfer from beneficiary Beneficiaries may transfer appeal rights to providers who provide the items or services and do not otherwise have appeal rights Form CMS-20031 must be completed and signed by the beneficiary and supplier to transfer the beneficiary’s appeal rights Harmony Healthcare International, Inc. 74Copyright © 2014 All Rights Reserved
  • 75. Appeal Rights Right to Appeal All appeal requests must be made in writing Harmony Healthcare International, Inc. 75Copyright © 2014 All Rights Reserved
  • 76. Appeal Rights Medicare offers five levels in the Part A and Part B Appeals Process: 1. Redetermination by a MAC 2. Reconsideration by a QIC 3. Hearing by an Administrative Law Judge (ALJ) 4. Review by the Medicare Appeals Council, within the Department Appeals Board 5. Judicial review in U.S. District Court Harmony Healthcare International, Inc. 76Copyright © 2014 All Rights Reserved
  • 77. 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 Harmony Healthcare International, Inc. 77Copyright © 2014 All Rights Reserved
  • 78. 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 Harmony Healthcare International, Inc. 78Copyright © 2014 All Rights Reserved
  • 79. 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 Harmony Healthcare International, Inc. 79Copyright © 2014 All Rights Reserved
  • 80. Harmony Healthcare International ADR Response And Appeal Packages Harmony Healthcare International, Inc. 80Copyright © 2014 All Rights Reserved
  • 81. Additional Development Requests Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 81
  • 82. Additional Development Requests Medicare Contractors send providers additional development request (ADR) letters requesting additional documentation The ADR letters will be mailed and /or the claim in question will be in status location S B6001 that identifies claims in FISS that are in an ADR status/location Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 82
  • 83. Additional Development Requests Do not submit replacement/duplicate claims for the ones pending in medical review The submission of replacement/duplicate claims will result in claim denial, rejection or recoupment This will p r o l o n g the medical review process Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 83
  • 84. Additional Development Requests When the claim is finalized, the claim will have paid in full or part, or denied If you disagree with the decision, you can request a redetermination/1st level of appeal within 120 days of the determination (date on the remittance advice) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 84
  • 85. Additional Development Requests After the 45th day, if the documentation needed to make a medical determination is not received, the claim may be denied as records not received timely and these claim denials are issued with Remittance Advice Code N102/56900 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 85
  • 86. Additional Development Requests CMS guidelines allow contractors the time frame of 60 days to complete the review from the date on which the last of the requested medical records is received Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 86
  • 87. Harmony Healthcare International The Appeal Harmony Healthcare International, Inc. 87Copyright © 2014 All Rights Reserved
  • 88. The Appeal Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 88 Assign a team leader to oversee the preparation of the denial package Work as a team to gather pertinent information for the Medicare Appeal Review the medical record to ensure completeness
  • 89. The Appeal 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 Harmony Healthcare International, Inc. 89Copyright © 2014 All Rights Reserved
  • 90. Monitor the Appeal Internal tracking system to monitor When ADR or denial was received When package was sent out Final results of the review Harmony Healthcare International, Inc. 90Copyright © 2014 All Rights Reserved
  • 91. The Appeal In order to effectively manage a Medicare denial, the facility must work as a team to gather pertinent information Assign a team leader to oversee the preparation of the denial package All members of the team should review the medical record to ensure completeness Harmony Healthcare International, Inc. 91Copyright © 2014 All Rights Reserved
  • 92. The Appeal 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 Harmony Healthcare International, Inc. 92Copyright © 2014 All Rights Reserved
  • 93. The Appeal 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 listed in the ADR/decision statement to include in the medical record Consider additional info not listed that will support the services provided Harmony Healthcare International, Inc. 93Copyright © 2014 All Rights Reserved
  • 94. ADR/Help Letter Checklist Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 94 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 ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
  • 95. 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 Harmony Healthcare International, Inc. 95Copyright © 2014 All Rights Reserved
  • 96. The Appeal Package Important to know the consequences if the facility does not submit all necessary paperwork Facility needs to review the packet carefully to avoid a technical denial based on missing information including signatures Harmony Healthcare International, Inc. 96Copyright © 2014 All Rights Reserved
  • 97. 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 Harmony Healthcare International, Inc. 97Copyright © 2014 All Rights Reserved
  • 98. Appeals Process PREP Include a statement of position letter with the medical record documentation to the reviewing agency explaining the services provided to the patient Harmony Healthcare International, Inc. 98Copyright © 2014 All Rights Reserved
  • 99. Monitor the Appeal Harmony Healthcare International, Inc. 99Copyright © 2014 All Rights Reserved
  • 100. Monitor the Appeal Internal tracking system to monitor When ADR or denial was received When package was sent out Final results of the review Harmony Healthcare International, Inc. 100Copyright © 2014 All Rights Reserved
  • 101. Harmony Healthcare International Redetermination and Reconsideration Harmony Healthcare International, Inc. 101Copyright © 2014 All Rights Reserved
  • 102. Redetermination and Reconsideration If a claim is initially denied, there is action the facility can take The first stage is the Redetermination The next step is a Reconsideration Harmony Healthcare International, Inc. 102Copyright © 2014 All Rights Reserved
  • 103. Redetermination An examination of a claim by a review agency who is different from the agency who made the initial determination The facility has 120 days from the date of receipt of the initial claim determination to file an appeal A minimum monetary threshold is not required to request a determination Harmony Healthcare International, Inc. 103Copyright © 2014 All Rights Reserved
  • 104. Redetermination Include an appeal letter that outlines 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 Harmony Healthcare International, Inc. 104Copyright © 2014 All Rights Reserved
  • 105. Redetermination Appeal Letter An explanation of skilled therapy services provided to the patient Medicare guidelines used in the skilled care decision making process, if applicable Harmony Healthcare International, Inc. 105Copyright © 2014 All Rights Reserved
  • 106. Redetermination Any additional supporting documentation not submitted during the Help letter phase from the medical record should be submitted along with the redetermination request Highlight Add sticky tabs The redetermination request should be sent to the contractor that issued the initial determination Harmony Healthcare International, Inc. 106Copyright © 2014 All Rights Reserved
  • 107. Redetermination Contractors will generally issue a decision within 60 days of receipt of redetermination request in the form of : A letter A Medicare Redetermination Notice (MRN) Revised remittance advice Harmony Healthcare International, Inc. 107Copyright © 2014 All Rights Reserved
  • 108. Reconsideration If the request for redetermination results in a denial, a reconsideration can be requested A QIC will conduct the reconsideration request The QIC reconsideration process allows for an independent review of medical necessity by a panel of physicians or other health-care professions A minimum monetary threshold is not required to request a reconsideration Harmony Healthcare International, Inc. 108Copyright © 2014 All Rights Reserved
  • 109. Reconsideration A written reconsideration request must be filed within 180 days of receipt of the redetermination Instructions are provided on the Medicare Redetermination Notice (MRN) A Request for reconsideration may be made on Form CMS-20033. This form will be mailed with the MRN Harmony Healthcare International, Inc. 109Copyright © 2014 All Rights Reserved
  • 110. Reconsideration Include a letter outlining the argument for payment The request should clearly explain why the facility disagrees with the redetermination A copy of the MRN, and any other supportive documentation, should be sent with the reconsideration request to the QIC identified in the MRN Harmony Healthcare International, Inc. 110Copyright © 2014 All Rights Reserved
  • 111. Reconsideration Reconsiderations are conducted on-the- record; and in most cases, the QIC will send its decision to all parties within 60 days of receipt of the request for reconsideration The decision will contain detailed info on further appeal rights if the decision is not fully favorable Harmony Healthcare International, Inc. 111Copyright © 2014 All Rights Reserved
  • 112. Reconsideration If the QIC cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to an ALJ Harmony Healthcare International, Inc. 112Copyright © 2014 All Rights Reserved
  • 113. A Successful ALJ Hearing Harmony Healthcare International, Inc. 113Copyright © 2014 All Rights Reserved
  • 114. 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 The facility must send a notice of the ALJ hearing request to the QIC on the hearing request form or in the written request Harmony Healthcare International, Inc. 114Copyright © 2014 All Rights Reserved
  • 115. ALJ Overview A letter to request the ALJ hearing should simply highlight the most pertinent reasons justifying payment Harmony Healthcare International, Inc. 115Copyright © 2014 All Rights Reserved
  • 116. ALJ Overview ALJ hearings are generally held by video-teleconference (VTC) or by telephone If the facility prefers not to have a VTC or telephone hearing, they may ask for an in-person hearing, but they must demonstrate the necessity for an in- person hearing Harmony Healthcare International, Inc. 116Copyright © 2014 All Rights Reserved
  • 117. ALJ Overview The ALJ will determine whether an in- person hearing is warranted on a case-by- case basis Facilities may also ask the ALJ to make a decision without a hearing (on-the- record). CMS or its contractors may participate in an ALJ hearing, but they must provide notice to the ALJ and all parties of the hearing Harmony Healthcare International, Inc. 117Copyright © 2014 All Rights Reserved
  • 118. ALJ Overview ALJ will generally issue a decision within 90 days of receipt of the hearing request The timeframe may be extended for a variety of reasons including, but not limited to: The case being escalated from the reconsideration level The submission of additional evidence not included with the hearing request The request for an in-person hearing The facility’s failure to send notice of the hearing request to other parties and The initiation of discovery if CMS is a party Harmony Healthcare International, Inc. 118Copyright © 2014 All Rights Reserved
  • 119. ALJ Overview If the ALJ does not issue a decision within the applicable timeframe, you may ask the ALJ to escalate the case to the Appeals Council level Harmony Healthcare International, Inc. 119Copyright © 2014 All Rights Reserved
  • 120. ALJ Hearing Preparation Harmony Healthcare International, Inc. 120Copyright © 2014 All Rights Reserved
  • 121. ALJ Office of Medicare Hearings and Appeals (OHMA) Administrative law judge hearings will not be assigned to a judge for at least two years OMHA stopped assigning new hearing requests from providers as of July 15, 2013 The weekly influx of hearing requests surged from an average of 1,250 in January 2012 to more than 15,000 in December 2013 Medicare Appellant Forum to provide updates to OMHA appellants on the status of OMHA operations http://www.hhs.gov/omha/omha_medicare_appellant_for um.html Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 121
  • 122. ALJ Hearing Preparation Appeal Process Discuss and study CMS Guidelines Discuss type of ALJ hearing (video, phone, in person) to anticipate the format Goals of the Hearing Inform the Judge of skilled services Get the claim paid Harmony Healthcare International, Inc. 122Copyright © 2014 All Rights Reserved
  • 123. ALJ Hearing Preparation Team Preparation Medical record review Outline of speaking points Select a point person for the hearing Team input Harmony Healthcare International, Inc. 123Copyright © 2014 All Rights Reserved
  • 124. ALJ Hearing Hearing Process Prepare the facility designated hearing room for video or phone hearings Judge’s assistant will initiate the phone contact (test phone lines and speakers) Introductions Statement by facility Offer to fax any pertinent documents discussed during the hearing Harmony Healthcare International, Inc. 124Copyright © 2014 All Rights Reserved
  • 125. ALJ Hearing Organize documentation Keep pertinent notes or forms at your finger tips Number the pages for reference Have the staff that worked with patient on the call Speak respectfully, clearly, slowly Provide a concise summary Harmony Healthcare International, Inc. 125Copyright © 2014 All Rights Reserved
  • 126. ALJ Hearing Be prepared to answer questions prepared by the Judge Why did the patient require skilled therapy when they were hospitalized for a UTI? Where does the medical record state that continued therapy services were necessary after the initial date in question? Explain why skilled care continued although the notes indicate the patient did not have an exacerbation of medical condition? Harmony Healthcare International, Inc. 126Copyright © 2014 All Rights Reserved
  • 127. ALJ Hearing Be prepared to answer questions asked by the Judge When did the patient get discharged from therapy services? Why do the daily nursing notes state the patient was ambulating ad lib, yet physical therapy continued to provide skilled treatment? Harmony Healthcare International, Inc. 127Copyright © 2014 All Rights Reserved
  • 128. Conclusion Educate, Discuss and Prepare Don’t Wait for Medicare Medical Review Communicate to all Staff Medicare Skilled Care Criteria Refine Interdisciplinary Management of Medicare Appeals Establish and Maintain Peer Review and External Review of Records to Assure Insulation of Claims Harmony Healthcare International, Inc. 128Copyright © 2014 All Rights Reserved
  • 129. Keys to Success Provide clinically appropriate care Document Medical necessity Deficits Outcomes Meet technical requirements Review entire medical record Respond to ADRs timely Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 129
  • 130. Questions/Answers Harmony Healthcare International (978) 887 - 8919 www.Harmony-Healthcare.com Cmullin@Harmony-Healthcare.com @KrisMastrangelo @Harmonyhlthcare facebook.com/HarmonyHealthcareInternational H linkedin.com/company/harmony-healthcare Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 130
  • 131. Copyright © 2014 All Rights Reserved Register online http://info.harmony-healthcare.com/harmony2014 or by phone (978) 887-8919 ext. 13 Register Online Harmony Healthcare International, Inc. 131
  • 132. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 132
  • 133. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 133

Notas del editor

  1. Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a “daily basis,” i.e., on essentially a 7 days a week basis. A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least 5 days a week. (If therapy services are provided less than 5 days a week, the “daily” requirement would not be met.) This requirement should not be applied so strictly that it would not be met merely because there is an isolated break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would not be practical. In instances when a patient requires a skilled restorative nursing program to positively affect his functional well-being, the expectation is that the program be rendered at least 6 days a week. (Note that when a patient’s skilled status is based on a restorative program, medical evidence must exist to justify the services. In most instances, it is expected that a skilled restorative program will be, at most, only a few weeks in duration.)
  2. This slide highlights that it is the level of care requirement to which presumption applies – there is no presumption of reasonable and necessary, meeting the practical matter criterion or any other requirements. Keep in mind that Presumption simply means there is a strong likelihood that beneficiaries assigned to one of the upper 52 RUG-IV groups during the immediate post-hospital period require a covered level of care.
  3. Review the slide.Chapter 8 of the MBPM goes on to state that “skilled observation and assessment may also be required for patients whose primary condition and needs are psychiatric in nature or for patients who, in addition to their physical problems, have a secondary psychiatric diagnosis. These patients may exhibit acute psychological symptoms such as depression, anxiety or agitation, which require skilled observation and assessment such as observing for indications of suicidal or hostile behavior. However, these conditions often require considerably more specialized, sophisticated nursing techniques and physician attention than is available in most participating SNFs. Therefore, these cases must be carefully documented.
  4. According to CMS, “Reasonable probability” means that a potential complication or further acute episode was a likely possibility.