Más contenido relacionado Similar a How to Review Medicare Appeals in the SNF (20) Más de Harmony Healthcare International (HHI) (20) How to Review Medicare Appeals in the SNF1. 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
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.”
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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
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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 “
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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
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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”
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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
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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
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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
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21. What is Skilled Care ?
Direct Skilled Nursing Services
Management and Evaluation of a Care
Plan
Observation and Assessment
Teaching and Training
Skilled Rehabilitation
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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
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23. Skilled Services Categories:
Nursing Inherent Complexity
Inherent Complexity – Direct skilled
nursing services including:
IV feeding
IV meds
Suctioning
Tracheostomy Care
Ventilator support
Ulcers
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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
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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.
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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
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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
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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).
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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
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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
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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
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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.
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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.
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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).
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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
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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
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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
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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
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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…
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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 ________
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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
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Recovery Audit Contractors
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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.
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Recovery Audit Contractors
If you bill fee-for-service programs, your
claims will be subject to review by the
Recovery Auditors.
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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
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75. Appeal Rights
Right to Appeal
All appeal requests must be
made in writing
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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
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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
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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
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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
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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
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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
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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
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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
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88. The Appeal
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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
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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
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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
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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
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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
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94. ADR/Help Letter Checklist
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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113. A Successful ALJ Hearing
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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
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115. ALJ Overview
A letter to request the ALJ hearing
should simply highlight the most
pertinent reasons justifying
payment
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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
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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
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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
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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
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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
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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
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123. ALJ Hearing Preparation
Team Preparation
Medical record review
Outline of speaking points
Select a point person for the
hearing
Team input
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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
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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
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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?
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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?
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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
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129. Keys to Success
Provide clinically appropriate care
Document
Medical necessity
Deficits
Outcomes
Meet technical requirements
Review entire medical record
Respond to ADRs timely
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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
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131. Copyright © 2014 All Rights Reserved
Register online
http://info.harmony-healthcare.com/harmony2014
or by phone (978) 887-8919 ext. 13
Register Online
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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
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133. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 133
Notas del editor 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.) 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. 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. According to CMS, “Reasonable probability” means that a potential complication or further acute episode was a likely possibility.