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Skilled Rehabilitation Services:
Avoiding Denied Claims
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. (HHI)
Presented by:
Keri Hart, MS CCC SLP, RAC-CT
Director of CHHRP Program Development
Speaker Bio
Nearly 25 Years Experience in Long-term Care
Corporate Director of Clinical
Reimbursement Services
MDS
Corporate Rehab Director
Rehab Director
SLP
Cognition (Dementia and Head Injury)
Head and Neck (Dysphagia and Voice)
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
Increase in Medicare Documentation
Reviews
Understanding why an increase in
Medicare Part A and Part B has
occurred will allow providers to
identify their risk areas
Understanding trends in denials for
Medicare Part A and Part B has
occurred will allow providers to
identify their risk are
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
Documentation
Ensure rehabilitation documentation
supports:
Part A coverage criteria
Part B coverage criteria
Documentation of deficits
Requires the skills of a therapist
Evidence of Progress
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
Increase in Medicare Documentation
Reviews
Significant increase in the number of medical review
requests from Medicare Administrative Contractors
(MACs)
Medicare Part A and B
Billing inconsistencies
ICD-9 Coding triggers
Similar pattern to Medical Record Reviews within
the nursing facility setting in the early 90's
Number of "Help Letters“ was astoundingly high
Investigations into potential fraudulent billing
practices increased
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 5
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 6
Zone Program Integrity Contractor
(ZPIC)
Goal is to identify Fraud
CMS launched another major initiative to
target providers other than the hospital
setting as the RAC auditors have been
focusing on hospital audits
Southeast, South Central, Midwest,
Northeast and West Coast regions of the
U.S. are seeing the most ZPIC audits at
this time
ZPIC
Zone Program Integrity Contractors (ZPICs) 
Medicare fraud and abuse prevention and detection
Result of these audits may be prepayment review
for up to a year
Very Costly
Unannounced on site visits
Pre-Payment review after submission of ADR
ZPICs can take as long as they want to review and
make a determination on a given claim.
Notice is lacking, and SNF providers are often
taken by surprise
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 8
Zone Program Integrity Contractor
(ZPIC)
ZPICs
SafeGuard Services
AdvanceMed
Health integrity
Integriguard
Surprise on-site visits
Targeted data analysis
100 Days
Return Admissions
Long Term Residents
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 9
On-site Medical Record
Review Audits
Interviews of Rehab Staff and MDS Questions
Sample therapy staff interview questions:
1. Do you feel pressure to meet your RUG levels?
2. Who has the say on discharge from therapy?
Sample MDS staff interview questions:
1. Who decides the ARD?
2. Do they provide group and concurrent
treatments?
OIG Report November 2012
In fiscal year (FY) 2012, Medicare paid $32.2 billion
for SNF services
Submission of inaccurate, medically unnecessary,
and fraudulent claims
Medicare Payment Advisory Commission has raised
concerns about SNFs’ improperly billing for therapy
to obtain additional Medicare payments
Increase and expand reviews of SNF claims
Use CMS fraud prevention system to identify SNFs
billing higher paying RUGs
Monitor compliance with therapy assessments (COT)
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 11
OIG Findings
From 2006 to 2008, SNFs increasingly billed for
higher paying RUGs, even though beneficiary
characteristics remained largely unchanged
Percentage of RUGs for ultra high therapy increased
from 17 to 28 percent
Percentage of RUGs with high ADL scores increased
from 30 percent in 2006 to 34 percent in 2008
Even though SNFs significantly increased their
billing for these higher paying RUGs, beneficiaries’
ages and diagnoses at admission were largely
unchanged from 2006 to 2008
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 12
OIG Findings
For-profit SNFs were far more likely than
nonprofit or government SNFs to bill for
higher paying RUGs
32 percent of RUGs from for-profit SNFs
were for ultra high therapy, compared to 18
percent from nonprofit SNFs and 13 percent
from government SNFs. In addition, for-
profit SNFs had a higher use of RUGs with
high ADL scores than both for profit and
government SNFs. For-profit SNFs also had
longer lengths of stay, on average, compared
to those of the other types of SNFs.
OIG Report November 2012
OIG recommendations (CMS concurred):
1) Increase and expand reviews of SNF claims
2) Use CMS fraud prevention system to identify
SNFs billing higher paying RUGs
3) Monitor compliance with therapy assessments
(COT)
4) Change the current method for determining how
much therapy is needed to ensure appropriate
payments
5) Improve the accuracy of MDS items
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
CMS Results
Providers have received feedback
results for 2012 Medicare Part A from
their MAC
Summarizes initial medical record
determinations only
Does not include appeal results for
overturns and decision reversals
Similar trends across MACs
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
CMS Results
NHIC 2012 Example:
24.32 % did not respond to
Additional Documentation Request
(ADR)
43.44 % Denial Rate
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
CMS Results
NHIC 2012 Example (continued):
Denial Trends:
86.7 % Medical information provided
did not support the need for SNF Care
5.7% Missing Incomplete
Documentation of records received
1.27% No 3 Day Qualifying Hospital
Stay
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
Medicare Part B Reviews
Significant increase in the number of
medical review requests from Medicare
Administrative Contractors (MACs)
Exception Process
January 2012 initiation of clinical
outcomes directly on the Medicare Part
B bill
OIG Report
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 18
OIG Report
Part B
OIG report regarding Questionable Billing
for Medicare Outpatient Therapy Services
(Medicare Part B)
Medicare expenditures for outpatient
therapy increased 133 percent between
2000 and 2009, from $2.1 billion to $4.9
billion, while the number of Medicare
beneficiaries receiving outpatient therapy
increased only 26 percent from 3.6 million
to 4.5 million
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 19
OIG Report
Part B
Identified 20 counties that had in 2009:
The highest average Medicare payment per
beneficiary
More than $1 million in total Medicare payments
for outpatient therapy (i.e., high utilization
counties)
Analyzed Miami-Dade County, Florida, separately
because it had the highest average Medicare
payments per beneficiary among the high
utilization counties and the highest total Medicare
payments for outpatient therapy in 2009
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 20
OIG Report
Part B
Six questionable billing characteristics
that may indicate fraud:
(1) Services for which providers indicated
that an annual cap would be exceeded
(2) Beneficiaries whose providers indicated
that an annual therapy cap would be
exceeded on the beneficiaries first date of
service
(3) Payments for beneficiaries who
received outpatient therapy from multiple
providers
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 21
OIG Report
Part B
(4) Payments for therapy services provided
throughout the year
(5) Payments for services that exceeded an
annual cap
(6) Providers who were paid for more than
8 hours of outpatient therapy provided in a
single day
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 22
Findings
Medicare per-beneficiary spending on
outpatient therapy services in Miami-Dade
County was three times the national average in
2009
Medicare paid an average of $3,459 per Miami-
Dade beneficiary for outpatient therapy,
compared to an average of $1,078 nationally
Each therapy beneficiary in Miami-Dade County
received an average of 158 services during 2009,
while the national average was 49 services per
beneficiary
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 23
OIG Recommendations
Target outpatient therapy claims in high
utilization areas for further review
Target outpatient therapy claims with
questionable billing characteristics for further
review
Review geographic areas and providers with
questionable billing and take appropriate
action based on results
Revise the current therapy cap exception
process
Manual Medical Review for
Medicare Part B-April 2013
January 1st
2013 extended through December
31st
2013
Financial Limitation for Outpatient Therapy
Services – Section 3005 of the Middle Class
Tax Relief and Job Creation Act of 2012
Any providers billing therapy services
through Medicare Part B will be considered
outpatient therapy services
24Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
Manual Medical Review for
Medicare Part B-April 2013
Outpatient services includes:
Skilled Nursing Facilities
Long-term care facilities
Outpatient clinics
HOPDs (hospital-based outpatient clinics)
previously exempt from the therapy caps
Private practices
Home health agencies
25Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
Manual Medical Review for
Medicare Part B-April 2013
Similar to the therapy cap, there is a
threshold of $3,700 for PT and SLP
services combined and another
threshold of $3,700 for OT services.
Such requests for exceptions will be
manually medically reviewed.
26Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
Manual Medicare Reviews for
Medicare Part B-April 2013
April 2013: Providers will no longer be
required to submit requests for exceptions to
the threshold advance of furnishing therapy
services above the $3700
Recovery Auditors (RAC) will now conduct
prepayment review for all claims processed on or
after April 1, 2013. The specific process for
Manual Medical reviews is based on what state
services are provided.
27Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
Manual Medicare Reviews for
Medicare Part B-April 2013
The contractors will use the coverage
and payment policy requirements in
Section 220 of the Medicare Benefit
Policy manual and any applicable local
coverage decision policies when
making determinations for approving
therapy services above the threshold
 
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
Manual Medicare Reviews for
Medicare Part B-April 2013
Pre-Payment Review: Claims
submitted in the Recovery Audit
Prepayment Review Demonstration
states will be reviewed on a
prepayment basis.
These states are Florida, California,
Michigan, Texas, New York, Louisiana,
Illinois, Pennsylvania, Ohio, North
Carolina and Missouri.
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
Manual Medicare Reviews for
Medicare Part B-April 2013
Prepayment Review (Cont)
The Recovery Auditor will conduct
prepayment review within 10 business
days of receiving the additional
documentation requested and will
notify the MAC of the payment
decision. The facility’s MAC will then
notify the therapy provider of the
outcome of the decision.
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30
Manual Medicare Reviews for
Medicare Part B-April 2013
Post-payment Review: In the
remaining states, the Recovery Auditors
will conduct “immediate post-payment
review”. The MAC will flag the claims
that meet the criteria, request additional
documentation and pay the claim.
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 31
Manual Medicare Reviews for
Medicare Part B-April 2013
Post-payment Review (continued)
The MAC will send an ADR to the provider
requesting the additional documentation be sent
to the Recovery Auditor.
The Recovery Auditor will conduct post
payment review and will notify the MAC of the
payment decision. The facility’s MAC will then
notify the therapy provider of the outcome of
the decision.
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 32
Medicare Part B Reviews
Most MACs have updated their Local Coverage
Determinations (LCDs) for inclusion of the G Codes
requirements
Some have taken the opportunity to add additional
requirements
National Government Services: PT/OT January 2013:
“Where therapy exceeds an established cap, progress
reports will be required at least every 5 treatment days.
Writing progress notes more frequently than the
minimum is encouraged to support the medical
necessity of treatment.”
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 33
Denial Reasons
Technical
The provider did not meet a regulatory conditions
for payment
Difficult to win on appeal
Provider did not send the needed documentation
Clinical
Documentation does not justify the clinical need
for the service(s) provided
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 34
Technical Denial Reasons
Documentation not received within requested time
frame
Response to Additional Documentation Request
(ADR) did contain documentation requested
Physician Certification not signed or missing
Therapy Billing logs do not support billing
Part A – MDS Assessment does not support
Part B - 8 Minute Rule
Illegible documentation
Hospital documentation was not submitted
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35
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 did
not support continued progress
The amount, frequency and duration of
services were not reasonable, given the
patient’s current status
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 36
Clinical Denial Reasons
Documentation demonstrates that the
therapist worked long enough with the
beneficiary to develop a restorative
program
Practicing of previously taught
exercises does not require the skills of a
therapist
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37
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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38
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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
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've helped
the beneficiary progress versus skilled
rehabilitation services
40Harmony Healthcare International, Inc.Copyright © 2013 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
41Harmony Healthcare International, Inc.Copyright © 2013 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
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
46Harmony Healthcare International, Inc.Copyright © 2013 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
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
48Harmony Healthcare International, Inc.Copyright © 2013 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
49Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
Denial Reasons
Services provided were likely clinically
appropriate but the documentation did
not support:
Technical requirements
Need to receive an inpatient level of care
The skills of a therapist were required
Medical necessity
Functional outcome
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
ADR Response
Common practice to receive communications
from Medicare review agencies requesting
proof of skilled services
CMS online billing
Mail
Understand the process to manage the
inquiry in a timely and detailed manner in
order to minimize lost revenue
Harmony Healthcare International, Inc. 51Copyright © 2013 All Rights Reserved
ADR Response
Raise facility awareness
Function as a TEAM
Communication
Organization
Harmony Healthcare International, Inc. 52Copyright © 2013 All Rights Reserved
ADR Response
The process starts with an Additional
Development Request (ADR)
These can be triggered by items specific
to the patient, such as:
RUG score
ICD-9 Codes on Bill
Wide spread probe
Harmony Healthcare International, Inc. 53Copyright © 2013 All Rights Reserved
The Appeal
The following team members are beneficial in this
process:
Rehabilitation Director
Therapists who provided care
Medical Records
MDS Coordinator
Director of Nursing
Restorative Nursing Program Manager
Social Services
Dietary
Additional team members who participated in care
Harmony Healthcare International, Inc. 54Copyright © 2013 All Rights Reserved
ADR Response
Assign a team leader to oversee the
preparation of the response package
Carefully read the request for records
Due Date
Documents requested
Review MAC specific requirements
Where to send
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55
ADR Response
PREP
(Proper Reimbursement Explanation Paper)
Include a statement of position letter with
the medical record documentation to the
reviewing agency explaining the services
provided to the patient
Identify potential risk areas
Summarize skilled care provided
Add additional documents to support the
claim
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
ADR Response
Each team member should review the
package as a whole
The team leader should have a final
look prior to submitting the appeal
Always keep a copy of the packet sent
to the reviewing agency
Harmony Healthcare International, Inc. 57Copyright © 2013 All Rights Reserved
Tracking Results
Internal tracking system to monitor
When ADR or denial was received
When package was sent out
Final results of the review
Keep a copy of records sent
Communicate results with the Team
Harmony Healthcare International, Inc. 58Copyright © 2013 All Rights Reserved
Denial Process
It is not uncommon for an ADR to result in
the denial of part or all of a claim
Once an initial claim determination is
made providers have the right to appeal
All appeal requests must be made in
writing
Harmony Healthcare International, Inc. 59Copyright © 2013 All Rights Reserved
Denial Process
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. 60Copyright © 2013 All Rights Reserved
Keys to Success
Provide clinically appropriate care
Understand the requirements for Medicare
Part A and B for your specific MAC
Local coverage determinations (LCDs)
Document care provided
Why were the skilled hands of a therapist
needed?
Medical necessity
Deficits
Outcomes
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61
Keys to Success
Utilize a checklist to ensure all
documents are included
Was a copy of the original signed
certification sent or a copy of the unsigned
copy?
Respond to ADRs timely
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62
What is a CHHRP-LTC?
A Certified Harmony Healthcare
Rehabilitation Professional (CHHRP-
LTC) is an Interdisciplinary
Professional who has Successfully
Completed an Intensive and Clinically-
Founded Training Geared Specifically
to Patients in a Skilled Nursing Facility
(SNF) Setting.
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
What is a CHHRP-LTC?
3 Day Certification Includes:
CEUs
Medicare Therapy Documentation in a
SNF 
Medicare Coverage Criteria
Rehabilitation Program Development
MDS Coding for the Therapy Professional
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64
What is a CHHRP-LTC?
Hot Topics Discussed:
Office of Inspector General (OIG) Report
Functional Reporting of G-Codes
The Jimmo Settlement Agreement
Updated 2013 Process for Manual Medical
Review of Part B  Therapy
2013 Multiple Procedure Payment
Reduction (MPPR)
Medicare Part A an B Denial Trends
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65
What is a CHHRP-LTC?
info.harmony-healthcare.com/chhrp
See Upcoming CHHRP-LTC
Certification Programs
Host a CHHRP-LTC Certification
Programs and earn free attendees
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
www.Harmony-Healthcare.com
Follow Me & HHI on Twitter
@ChhrpHart
@Harmonyhlthcare
67Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

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Skilled Rehab Services: Avoiding Denied Claims

  • 1. Skilled Rehabilitation Services: Avoiding Denied Claims HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Keri Hart, MS CCC SLP, RAC-CT Director of CHHRP Program Development
  • 2. Speaker Bio Nearly 25 Years Experience in Long-term Care Corporate Director of Clinical Reimbursement Services MDS Corporate Rehab Director Rehab Director SLP Cognition (Dementia and Head Injury) Head and Neck (Dysphagia and Voice) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  • 3. Increase in Medicare Documentation Reviews Understanding why an increase in Medicare Part A and Part B has occurred will allow providers to identify their risk areas Understanding trends in denials for Medicare Part A and Part B has occurred will allow providers to identify their risk are Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  • 4. Documentation Ensure rehabilitation documentation supports: Part A coverage criteria Part B coverage criteria Documentation of deficits Requires the skills of a therapist Evidence of Progress Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
  • 5. Increase in Medicare Documentation Reviews Significant increase in the number of medical review requests from Medicare Administrative Contractors (MACs) Medicare Part A and B Billing inconsistencies ICD-9 Coding triggers Similar pattern to Medical Record Reviews within the nursing facility setting in the early 90's Number of "Help Letters“ was astoundingly high Investigations into potential fraudulent billing practices increased Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 5
  • 6. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 6 Zone Program Integrity Contractor (ZPIC) Goal is to identify Fraud CMS launched another major initiative to target providers other than the hospital setting as the RAC auditors have been focusing on hospital audits Southeast, South Central, Midwest, Northeast and West Coast regions of the U.S. are seeing the most ZPIC audits at this time
  • 7. ZPIC Zone Program Integrity Contractors (ZPICs)  Medicare fraud and abuse prevention and detection Result of these audits may be prepayment review for up to a year Very Costly Unannounced on site visits Pre-Payment review after submission of ADR ZPICs can take as long as they want to review and make a determination on a given claim. Notice is lacking, and SNF providers are often taken by surprise Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  • 8. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 8 Zone Program Integrity Contractor (ZPIC) ZPICs SafeGuard Services AdvanceMed Health integrity Integriguard Surprise on-site visits Targeted data analysis 100 Days Return Admissions Long Term Residents
  • 9. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 9 On-site Medical Record Review Audits Interviews of Rehab Staff and MDS Questions Sample therapy staff interview questions: 1. Do you feel pressure to meet your RUG levels? 2. Who has the say on discharge from therapy? Sample MDS staff interview questions: 1. Who decides the ARD? 2. Do they provide group and concurrent treatments?
  • 10. OIG Report November 2012 In fiscal year (FY) 2012, Medicare paid $32.2 billion for SNF services Submission of inaccurate, medically unnecessary, and fraudulent claims Medicare Payment Advisory Commission has raised concerns about SNFs’ improperly billing for therapy to obtain additional Medicare payments Increase and expand reviews of SNF claims Use CMS fraud prevention system to identify SNFs billing higher paying RUGs Monitor compliance with therapy assessments (COT) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  • 11. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 11 OIG Findings From 2006 to 2008, SNFs increasingly billed for higher paying RUGs, even though beneficiary characteristics remained largely unchanged Percentage of RUGs for ultra high therapy increased from 17 to 28 percent Percentage of RUGs with high ADL scores increased from 30 percent in 2006 to 34 percent in 2008 Even though SNFs significantly increased their billing for these higher paying RUGs, beneficiaries’ ages and diagnoses at admission were largely unchanged from 2006 to 2008
  • 12. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 12 OIG Findings For-profit SNFs were far more likely than nonprofit or government SNFs to bill for higher paying RUGs 32 percent of RUGs from for-profit SNFs were for ultra high therapy, compared to 18 percent from nonprofit SNFs and 13 percent from government SNFs. In addition, for- profit SNFs had a higher use of RUGs with high ADL scores than both for profit and government SNFs. For-profit SNFs also had longer lengths of stay, on average, compared to those of the other types of SNFs.
  • 13. OIG Report November 2012 OIG recommendations (CMS concurred): 1) Increase and expand reviews of SNF claims 2) Use CMS fraud prevention system to identify SNFs billing higher paying RUGs 3) Monitor compliance with therapy assessments (COT) 4) Change the current method for determining how much therapy is needed to ensure appropriate payments 5) Improve the accuracy of MDS items Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
  • 14. CMS Results Providers have received feedback results for 2012 Medicare Part A from their MAC Summarizes initial medical record determinations only Does not include appeal results for overturns and decision reversals Similar trends across MACs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  • 15. CMS Results NHIC 2012 Example: 24.32 % did not respond to Additional Documentation Request (ADR) 43.44 % Denial Rate Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
  • 16. CMS Results NHIC 2012 Example (continued): Denial Trends: 86.7 % Medical information provided did not support the need for SNF Care 5.7% Missing Incomplete Documentation of records received 1.27% No 3 Day Qualifying Hospital Stay Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  • 17. Medicare Part B Reviews Significant increase in the number of medical review requests from Medicare Administrative Contractors (MACs) Exception Process January 2012 initiation of clinical outcomes directly on the Medicare Part B bill OIG Report Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  • 18. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 18 OIG Report Part B OIG report regarding Questionable Billing for Medicare Outpatient Therapy Services (Medicare Part B) Medicare expenditures for outpatient therapy increased 133 percent between 2000 and 2009, from $2.1 billion to $4.9 billion, while the number of Medicare beneficiaries receiving outpatient therapy increased only 26 percent from 3.6 million to 4.5 million
  • 19. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 19 OIG Report Part B Identified 20 counties that had in 2009: The highest average Medicare payment per beneficiary More than $1 million in total Medicare payments for outpatient therapy (i.e., high utilization counties) Analyzed Miami-Dade County, Florida, separately because it had the highest average Medicare payments per beneficiary among the high utilization counties and the highest total Medicare payments for outpatient therapy in 2009
  • 20. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 20 OIG Report Part B Six questionable billing characteristics that may indicate fraud: (1) Services for which providers indicated that an annual cap would be exceeded (2) Beneficiaries whose providers indicated that an annual therapy cap would be exceeded on the beneficiaries first date of service (3) Payments for beneficiaries who received outpatient therapy from multiple providers
  • 21. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 21 OIG Report Part B (4) Payments for therapy services provided throughout the year (5) Payments for services that exceeded an annual cap (6) Providers who were paid for more than 8 hours of outpatient therapy provided in a single day
  • 22. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 22 Findings Medicare per-beneficiary spending on outpatient therapy services in Miami-Dade County was three times the national average in 2009 Medicare paid an average of $3,459 per Miami- Dade beneficiary for outpatient therapy, compared to an average of $1,078 nationally Each therapy beneficiary in Miami-Dade County received an average of 158 services during 2009, while the national average was 49 services per beneficiary
  • 23. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 23 OIG Recommendations Target outpatient therapy claims in high utilization areas for further review Target outpatient therapy claims with questionable billing characteristics for further review Review geographic areas and providers with questionable billing and take appropriate action based on results Revise the current therapy cap exception process
  • 24. Manual Medical Review for Medicare Part B-April 2013 January 1st 2013 extended through December 31st 2013 Financial Limitation for Outpatient Therapy Services – Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012 Any providers billing therapy services through Medicare Part B will be considered outpatient therapy services 24Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 25. Manual Medical Review for Medicare Part B-April 2013 Outpatient services includes: Skilled Nursing Facilities Long-term care facilities Outpatient clinics HOPDs (hospital-based outpatient clinics) previously exempt from the therapy caps Private practices Home health agencies 25Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 26. Manual Medical Review for Medicare Part B-April 2013 Similar to the therapy cap, there is a threshold of $3,700 for PT and SLP services combined and another threshold of $3,700 for OT services. Such requests for exceptions will be manually medically reviewed. 26Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 27. Manual Medicare Reviews for Medicare Part B-April 2013 April 2013: Providers will no longer be required to submit requests for exceptions to the threshold advance of furnishing therapy services above the $3700 Recovery Auditors (RAC) will now conduct prepayment review for all claims processed on or after April 1, 2013. The specific process for Manual Medical reviews is based on what state services are provided. 27Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 28. Manual Medicare Reviews for Medicare Part B-April 2013 The contractors will use the coverage and payment policy requirements in Section 220 of the Medicare Benefit Policy manual and any applicable local coverage decision policies when making determinations for approving therapy services above the threshold   Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
  • 29. Manual Medicare Reviews for Medicare Part B-April 2013 Pre-Payment Review: Claims submitted in the Recovery Audit Prepayment Review Demonstration states will be reviewed on a prepayment basis. These states are Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
  • 30. Manual Medicare Reviews for Medicare Part B-April 2013 Prepayment Review (Cont) The Recovery Auditor will conduct prepayment review within 10 business days of receiving the additional documentation requested and will notify the MAC of the payment decision. The facility’s MAC will then notify the therapy provider of the outcome of the decision. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30
  • 31. Manual Medicare Reviews for Medicare Part B-April 2013 Post-payment Review: In the remaining states, the Recovery Auditors will conduct “immediate post-payment review”. The MAC will flag the claims that meet the criteria, request additional documentation and pay the claim. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 31
  • 32. Manual Medicare Reviews for Medicare Part B-April 2013 Post-payment Review (continued) The MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor. The Recovery Auditor will conduct post payment review and will notify the MAC of the payment decision. The facility’s MAC will then notify the therapy provider of the outcome of the decision. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 32
  • 33. Medicare Part B Reviews Most MACs have updated their Local Coverage Determinations (LCDs) for inclusion of the G Codes requirements Some have taken the opportunity to add additional requirements National Government Services: PT/OT January 2013: “Where therapy exceeds an established cap, progress reports will be required at least every 5 treatment days. Writing progress notes more frequently than the minimum is encouraged to support the medical necessity of treatment.” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 33
  • 34. Denial Reasons Technical The provider did not meet a regulatory conditions for payment Difficult to win on appeal Provider did not send the needed documentation Clinical Documentation does not justify the clinical need for the service(s) provided Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 34
  • 35. Technical Denial Reasons Documentation not received within requested time frame Response to Additional Documentation Request (ADR) did contain documentation requested Physician Certification not signed or missing Therapy Billing logs do not support billing Part A – MDS Assessment does not support Part B - 8 Minute Rule Illegible documentation Hospital documentation was not submitted Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35
  • 36. 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 did not support continued progress The amount, frequency and duration of services were not reasonable, given the patient’s current status Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 36
  • 37. Clinical Denial Reasons Documentation demonstrates that the therapist worked long enough with the beneficiary to develop a restorative program Practicing of previously taught exercises does not require the skills of a therapist Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37
  • 38. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38
  • 39. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
  • 40. 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've helped the beneficiary progress versus skilled rehabilitation services 40Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 41. 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 41Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 42. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
  • 43. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  • 44. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
  • 45. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
  • 46. 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 46Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 47. 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 © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  • 48. 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 48Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 49. 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 49Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 50. Denial Reasons Services provided were likely clinically appropriate but the documentation did not support: Technical requirements Need to receive an inpatient level of care The skills of a therapist were required Medical necessity Functional outcome Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
  • 51. ADR Response Common practice to receive communications from Medicare review agencies requesting proof of skilled services CMS online billing Mail Understand the process to manage the inquiry in a timely and detailed manner in order to minimize lost revenue Harmony Healthcare International, Inc. 51Copyright © 2013 All Rights Reserved
  • 52. ADR Response Raise facility awareness Function as a TEAM Communication Organization Harmony Healthcare International, Inc. 52Copyright © 2013 All Rights Reserved
  • 53. ADR Response The process starts with an Additional Development Request (ADR) These can be triggered by items specific to the patient, such as: RUG score ICD-9 Codes on Bill Wide spread probe Harmony Healthcare International, Inc. 53Copyright © 2013 All Rights Reserved
  • 54. The Appeal The following team members are beneficial in this process: Rehabilitation Director Therapists who provided care Medical Records MDS Coordinator Director of Nursing Restorative Nursing Program Manager Social Services Dietary Additional team members who participated in care Harmony Healthcare International, Inc. 54Copyright © 2013 All Rights Reserved
  • 55. ADR Response Assign a team leader to oversee the preparation of the response package Carefully read the request for records Due Date Documents requested Review MAC specific requirements Where to send Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55
  • 56. ADR Response PREP (Proper Reimbursement Explanation Paper) Include a statement of position letter with the medical record documentation to the reviewing agency explaining the services provided to the patient Identify potential risk areas Summarize skilled care provided Add additional documents to support the claim Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
  • 57. ADR Response Each team member should review the package as a whole The team leader should have a final look prior to submitting the appeal Always keep a copy of the packet sent to the reviewing agency Harmony Healthcare International, Inc. 57Copyright © 2013 All Rights Reserved
  • 58. Tracking Results Internal tracking system to monitor When ADR or denial was received When package was sent out Final results of the review Keep a copy of records sent Communicate results with the Team Harmony Healthcare International, Inc. 58Copyright © 2013 All Rights Reserved
  • 59. Denial Process It is not uncommon for an ADR to result in the denial of part or all of a claim Once an initial claim determination is made providers have the right to appeal All appeal requests must be made in writing Harmony Healthcare International, Inc. 59Copyright © 2013 All Rights Reserved
  • 60. Denial Process 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. 60Copyright © 2013 All Rights Reserved
  • 61. Keys to Success Provide clinically appropriate care Understand the requirements for Medicare Part A and B for your specific MAC Local coverage determinations (LCDs) Document care provided Why were the skilled hands of a therapist needed? Medical necessity Deficits Outcomes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61
  • 62. Keys to Success Utilize a checklist to ensure all documents are included Was a copy of the original signed certification sent or a copy of the unsigned copy? Respond to ADRs timely Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62
  • 63. What is a CHHRP-LTC? A Certified Harmony Healthcare Rehabilitation Professional (CHHRP- LTC) is an Interdisciplinary Professional who has Successfully Completed an Intensive and Clinically- Founded Training Geared Specifically to Patients in a Skilled Nursing Facility (SNF) Setting. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
  • 64. What is a CHHRP-LTC? 3 Day Certification Includes: CEUs Medicare Therapy Documentation in a SNF  Medicare Coverage Criteria Rehabilitation Program Development MDS Coding for the Therapy Professional Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64
  • 65. What is a CHHRP-LTC? Hot Topics Discussed: Office of Inspector General (OIG) Report Functional Reporting of G-Codes The Jimmo Settlement Agreement Updated 2013 Process for Manual Medical Review of Part B  Therapy 2013 Multiple Procedure Payment Reduction (MPPR) Medicare Part A an B Denial Trends Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65
  • 66. What is a CHHRP-LTC? info.harmony-healthcare.com/chhrp See Upcoming CHHRP-LTC Certification Programs Host a CHHRP-LTC Certification Programs and earn free attendees Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
  • 67. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 www.Harmony-Healthcare.com Follow Me & HHI on Twitter @ChhrpHart @Harmonyhlthcare 67Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.