How to Review Medicare Appeals in the SNF

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Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. As a Skilled Nursing Facility leader, are you confident in your ability to appeal any and all denied claims that may arise in your building?

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  • 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.
  • How to Review Medicare Appeals in the SNF

    1. 1. How to Review the SNF Appeal Process HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Carrie Mullin OTR/L, RAC-CT Claims Review Specialist
    2. 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. 3. Objectives Learner will be able to summarize SNF Medicare qualifiers Learner will be able to articulate Audit Triggers Learner will be able to Summarize Medical Record Preparedness Learner will be able to Summarize the ADR and appeal process Learner will be able to articulate strategies for participation in ALJ Hearings Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 3
    4. 4. Documenting Medicare Skilled Coverage Requirements DEFENSE!! Copyright © 2014 All Rights Reserved 4Harmony Healthcare International, Inc. The KEY to Preventing Denials
    5. 5. Advice from Ben Franklin Copyright © 2014 All Rights Reserved “Either write something worth reading or do something worth writing.” “An ounce of prevention is worth a pound of cure.” 5Harmony Healthcare International, Inc.
    6. 6. Prevention The key to preventing denials is documentation of skilled services provided The key to documenting skilled services provided is understanding the Medicare requirements for coverage Copyright © 2014 All Rights Reserved 6Harmony Healthcare International, Inc.
    7. 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. 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. 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. 10. Chapter 8 Medicare Manual (2014) Rehabilitation Daily Single type of skilled rehabilitation every day, or by furnishing various types of skilled services on different days that collectively add up to “daily” skilled services. “Arbitrarily staggering the timing of various therapy modalities though the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a “daily basis.” To meet this requirement, the patient must actually need skilled rehabilitation services to be furnished on each of the days that the facility makes such services available “ Copyright © 2014 All Rights Reserved 10Harmony Healthcare International, Inc.
    11. 11. What is Skilled Care? Nature of service requires the skills of a licensed person (e.g. technical or professional personnel) Skilled services are provided directly by or under general supervision of a licensed nurse or therapist to assure the safety of the patient and to achieve the medically desired result Diagnosis and prognosis do not determine what is skilled care – it is the care of the patient that is the deciding factor Copyright © 2014 All Rights Reserved 11Harmony Healthcare International, Inc.
    12. 12. “Practical Matter” Criterion “As a practical matter, considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility” Copyright © 2014 All Rights Reserved 12Harmony Healthcare International, Inc.
    13. 13. “Practical Matter” Criterion 1. Outpatient services are not available in the area where the individual lives 2.Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective than placement in the skilled nursing facility Copyright © 2014 All Rights Reserved 13Harmony Healthcare International, Inc.
    14. 14. “Practical Matter” Criterion 3. The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/patient to reside there safely 4. If the use of alternative services would adversely affect the patient/patient’s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis Copyright © 2014 All Rights Reserved 14Harmony Healthcare International, Inc.
    15. 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. 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. 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. 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. 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. 20. Totality While it is true that dialysis is one of the discrete indicators for assignment to a RUG within the Special Care Low category – a category to which the level of care presumption applies for a short period of time at the start of a SNF stay – it is the totality of items and services included within a given RUG, not any one specific coded service, that actually serves to justify the presumption Copyright © 2014 All Rights Reserved 20Harmony Healthcare International, Inc.
    21. 21. What is Skilled Care ? Direct Skilled Nursing Services Management and Evaluation of a Care Plan Observation and Assessment Teaching and Training Skilled Rehabilitation Copyright © 2014 All Rights Reserved 21Harmony Healthcare International, Inc.
    22. 22. What is Skilled Care? Nursing Anchors the Skill Need to remain in a SNF Medical Complexity Supports Non-Therapy RUG Increased potential Lower 14 and reviews with October 1st Changes Copyright © 2014 All Rights Reserved 22Harmony Healthcare International, Inc.
    23. 23. Skilled Services Categories: Nursing Inherent Complexity Inherent Complexity – Direct skilled nursing services including: IV feeding IV meds Suctioning Tracheostomy Care Ventilator support Ulcers Copyright © 2014 All Rights Reserved 23Harmony Healthcare International, Inc.
    24. 24. Skilled Services Categories: Nursing Inherent Complexity Inherent Complexity Tube feedings Respiratory Therapy 7 days per week Surgical wound or open lesions with treatments Unstable clinically with diabetes with injections Transfusions Chemotherapy Colostomy Care, early post op care Copyright © 2014 All Rights Reserved 24Harmony Healthcare International, Inc.
    25. 25. Observation and Assessment Skilled services when the likelihood of change in a patient’s condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures, until the patient’s condition is essentially stabilized. Reasonable potential for a future complication or acute episode sufficient to justify the need for continued skilled observation and assessment. Copyright © 2014 All Rights Reserved 25Harmony Healthcare International, Inc.
    26. 26. Observation and Assessment Example (from Chapter 8 of the Medicare Benefit Policy Manual): A patient has been hospitalized following a heart attack, and following treatment but before mobilization, is transferred to the SNF Copyright © 2014 All Rights Reserved 26Harmony Healthcare International, Inc.
    27. 27. Observation and Assessment Example (continued): Because it is unknown whether exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated, until the patient’s treatment regimen is essentially stabilized Copyright © 2014 All Rights Reserved 27Harmony Healthcare International, Inc.
    28. 28. Observation and Assessment The medical documentation must describe the skilled services that require the involvement of nursing personnel to promote the stabilization of the patient's medical condition and safety (Effective 1/2014). Copyright © 2014 All Rights Reserved 28Harmony Healthcare International, Inc.
    29. 29. Observation and Assessment KEY POINT: If a patient was admitted for skilled observation but did not develop a further acute episode or other complications, the skilled observation services still are covered so long as there was a reasonable probability for such a complication or further acute episode Copyright © 2014 All Rights Reserved 29Harmony Healthcare International, Inc.
    30. 30. Observation and Assessment Fever Dehydration Septicemia Pneumonia Nutritional Risk Chemotherapy Weight loss Blood sugar control Impaired cognition Severe Mood and Behavior conditions Copyright © 2014 All Rights Reserved 30Harmony Healthcare International, Inc.
    31. 31. Observation and Assessment Neurological Respiratory Cardiac Circulatory Pain/Sensation Nutritional Gastrointestinal Genitourinary Musculoskeletal Skin Copyright © 2014 All Rights Reserved 31Harmony Healthcare International, Inc.
    32. 32. Skilled Services Categories: Management and Evaluation of a Care Plan Based on the Physician’s orders, these services require the involvement of skilled nursing to meet the resident’s Medical needs Promote recovery Ensure medical safety Copyright © 2014 All Rights Reserved 32Harmony Healthcare International, Inc.
    33. 33. Skilled Services Categories: Teaching and Training Teaching and Training: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen Copyright © 2014 All Rights Reserved 33Harmony Healthcare International, Inc.
    34. 34. Copyright © 2014 All Rights Reserved Skilled Rehabilitation Overview Directly related to a written plan of treatment. Requires knowledge/skills/judgment of qualified professional. Services must be considered under acceptable standards of clinical practice. Expectation of improvement of restorative potential in a reasonable and predictable amount of time…or… Establishment of a safe and effective maintenance program. 34Harmony Healthcare International, Inc.
    35. 35. Copyright © 2014 All Rights Reserved Medicare Benefit Policy The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist. 35Harmony Healthcare International, Inc.
    36. 36. Harmony Healthcare International, Inc. 36 Maintenance Therapy Maintenance Therapy. The repetitive services required to maintain function sometimes involve the use of complex and sophisticated therapy procedures and consequently, the judgment and skill of a physical therapist might be required for the safe and effective rendition of such services (see §214.1.B). Must be necessary for the establishment of a safe and effective maintenance program; or, the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program (Effective 1/2014). Copyright © 2014 All Rights Reserved 36Harmony Healthcare International, Inc.
    37. 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. 38. Jimmo v. Sebelius The Jimmo v. Sebelius lawsuit was brought on behalf of a nationwide class of Medicare beneficiaries by six individual Medicare beneficiaries and seven national organizations representing people with chronic conditions The Jimmo v. Sebelius case challenged Medicare's use of an "Improvement Standard" to make coverage determinations Copyright © 2014 All Rights Reserved 38Harmony Healthcare International, Inc.
    39. 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. 40. Jimmo v. Sebelius Expands Medicare Part A and Part B coverage to include the rendering of skilled nursing and therapy services necessary to maintain a person's condition and is not dependent on whether the Medicare beneficiary “will improve”. CMS Fact Sheet States this is simply a clarification Copyright © 2014 All Rights Reserved 40Harmony Healthcare International, Inc.
    41. 41. Jimmo v. Sebelius The judgment indicates that as long as a patient requires skills of a therapist or a nurse a patient would meet skilled coverage criteria despite not making functional gains Documentation must support the need for skilled therapy intervention Copyright © 2014 All Rights Reserved 41Harmony Healthcare International, Inc.
    42. 42. Skills of a Therapist or a Nurse Must require, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or a nurse that qualified personnel, trained caretakers or the patient cannot provide independently Copyright © 2014 All Rights Reserved 42Harmony Healthcare International, Inc.
    43. 43. Skilled Nursing Documentation What To Consider Including Patient is at high risk for … Skilled assessment of … Daily skilled monitoring of … Potential for recurrence of … Potential for the following complications… There is a likelihood of change related to… The medical regimen is not essentially stabilized as evidenced by… Copyright © 2014 All Rights Reserved 43Harmony Healthcare International, Inc.
    44. 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. 45. Skilled Nursing Documentation What To Consider Including Skilled neurological assessment resulted in… Daily skilled monitoring for signs and symptoms of exacerbation of _____ secondary to _______ Patient is high risk for ______ secondary to _______ Medications adjusted to _____________, ongoing skilled assessment of regimen to promote recovery and ensure medical safety Patient continues to require daily skilled nursing as his treatment regimen is not essentially stabilized and there is a potential for recurrence of ________ Copyright © 2014 All Rights Reserved 45Harmony Healthcare International, Inc.
    46. 46. Non-Supportive Nursing Documentation Plateau in progress Voiced no complaints Patient requires custodial care Patient requires intermittent care Patient is unable to follow directions Patient requires intermittent services Patient has poor rehabilitation potential Patients medical treatment is essentially stabilized Refuses to participate in therapy (instead give the reason the patient is unable) Condition stable Slept well/family into visit Copyright © 2014 All Rights Reserved 46Harmony Healthcare International, Inc.
    47. 47. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 47Harmony Healthcare International, Inc. 47 Recovery Audit Contractors
    48. 48. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 48Harmony Healthcare International, Inc. 48 Recovery Audit Contractors The Recovery Auditors Program Mission The Recovery Auditor detect and correct past improper payments so that CMS can implement actions that will prevent future improper payments: Providers can avoid submitting claims that do not comply with Medicare rules CMS can lower its error rate Taxpayers and future Medicare beneficiaries are protected.
    49. 49. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 49Harmony Healthcare International, Inc. 49 Recovery Audit Contractors If you bill fee-for-service programs, your claims will be subject to review by the Recovery Auditors.
    50. 50. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 50Harmony Healthcare International, Inc. 50 Recovery Audit Contractors The Recovery Audit Review Process: Recovery Auditors review claims on a post-payment basis Recovery Auditors use the same Medicare policies as Carriers, FIs and MACs: NCDs, LCDs and the CMS Manuals Three types of review: Automated (no medical record needed) Semi-Automated (claims review using data and potential human review of a medical record or other documentation) Complex (medical record required) Recovery Audits look back three years from the date the claim was paid Recovery Auditors are required to employ a staff consisting of nurses, therapists, certified coders and a physician CMD
    51. 51. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 51Harmony Healthcare International, Inc. 51 Recovery Audit Contractors The appeal process for Recovery Audit denials is the same as the appeal process for Carrier/FI/MAC denials Do not confuse the “Recovery Audit Programs’ Discussion Period” with the Appeals process If you disagree with the Recovery Auditor’s determination: Do not stop with sending a discussion letter File an appeal before the 120th day after the Demand letter.
    52. 52. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 52Harmony Healthcare International, Inc. 52 Recovery Audit Contractors Recovery Auditors will offer an opportunity for the provider to discuss the improper payment determination with the Recovery Auditors (this is outside the normal appeal process)
    53. 53. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 53Harmony Healthcare International, Inc. 53 Appeal Determinations
    54. 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. 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. 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. 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. 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. 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. 60. Denial Reasons Restorative Level of Care Skilled therapy was provided when non-skilled maintenance services would have been more appropriate Restorative level of care provided Documentation supports that restorative nursing could have helped the beneficiary progress versus skilled rehabilitation services 60Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
    61. 61. Denial Reasons Custodial Level of Care Skilled rehabilitation and nursing services were custodial in nature and could have been met with restorative nursing, family member, or nursing provision of intermittent skilled rehabilitation and nursing services and that needs were custodial in nature and could have been met with restorative nursing, family member, or nursing assistant 61Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
    62. 62. Denial Reasons Prior Level of Function The therapist ignored the patient’s prior level of function and set unrealistic goals Prior level of function was illegible. Prior level of function was blank. Patient's functional level had not changed when compared to his prior level of functioning documented in the medical record Weekly nursing progress notes demonstrate that the beneficiary required the same amount of assistance (extensive assistance) prior to and after the hospital stay Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 62
    63. 63. Denial Reasons Rehab Potential The medical record did not support that the condition of the patient would improve materially in a reasonable and generally predictable period of time Poor Rehab potential Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 63
    64. 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. 65. Denial Reasons Lack of Functional Progress Gains were not significant and there was no indication of carryover of the functional task Lack of documentation relating to the patient having the potential to show significant progress No significant improvement with functional ability The outcome of therapy treatment was not documented Failure to document a complete treatment plan as outlined in Documentation Required section Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 65
    66. 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. 67. Denial Reasons Modalities Electrical Stimulation used to treat motor function disorders, such as multiple sclerosis, is considered investigational and therefore, non-covered Electrical Stimulation used in the treatment of facial nerve paralysis, commonly known as Bell’s Palsy, is considered investigational and therefore, non-covered Diathermy and Ultrasound heat treatments for the treatment of asthma, bronchitis, or any other pulmonary condition are considered not reasonable and necessary, and therefore, non- covered 67Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
    68. 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. 69. Denial Reasons Inpatient Level of Care Documentation did not support the need for inpatient level of care No daily skilled care requiring a stay in the SNF Supervised level of care 69Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
    70. 70. Denial Reasons Medical Record Conflicts Nursing notes mostly dependent ADLs/functional tasks throughout the SNF stay. Nursing note indicated there was no improvement and fluctuation of progress with self-care tasks. MDS assessments indicate that the beneficiary's ability to perform functional tasks/ADLs did not improve from the 5-day to the 90-day assessment 70Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
    71. 71. Documentation to Support Identified Risk Areas Identify potential denial risk areas What might the reviewer have not seen in the documentation provided to lead the reviewer to deny services? What additional documentation may be included to further support skilled Rehabilitation and Nursing services provided? Consultations/ED Visits Care Plan Physician Progress Notes Social Services/Dietary Notes Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 71
    72. 72. Appeal Process Harmony Healthcare International, Inc. 72Copyright © 2014 All Rights Reserved
    73. 73. Appeal Rights Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 73
    74. 74. Appeal Rights Right to Appeal: If the Beneficiaries is the only one with the right to appeal given specific situations, provider must obtain transfer from beneficiary Beneficiaries may transfer appeal rights to providers who provide the items or services and do not otherwise have appeal rights Form CMS-20031 must be completed and signed by the beneficiary and supplier to transfer the beneficiary’s appeal rights Harmony Healthcare International, Inc. 74Copyright © 2014 All Rights Reserved
    75. 75. Appeal Rights Right to Appeal All appeal requests must be made in writing Harmony Healthcare International, Inc. 75Copyright © 2014 All Rights Reserved
    76. 76. Appeal Rights Medicare offers five levels in the Part A and Part B Appeals Process: 1. Redetermination by a MAC 2. Reconsideration by a QIC 3. Hearing by an Administrative Law Judge (ALJ) 4. Review by the Medicare Appeals Council, within the Department Appeals Board 5. Judicial review in U.S. District Court Harmony Healthcare International, Inc. 76Copyright © 2014 All Rights Reserved
    77. 77. Appeal Rights Redetermination A review of the claim by the MAC utilizing personnel who are different from the personnel who made the initial determination The appellant (individual filing the appeal) has 120 days from the date of receipt of initial denial to file an appeal A minimum monetary threshold is not required to request a redetermination Harmony Healthcare International, Inc. 77Copyright © 2014 All Rights Reserved
    78. 78. Appeal Rights Reconsideration If the facility is dissatisfied with result of redetermination, they may request a reconsideration A Qualified Independent Contractor (QIC) will conduct the reconsideration The reconsideration process is an independent review of medical necessity by a panel of physicians or other health care professionals A minimum monetary threshold is not required to request a reconsideration Harmony Healthcare International, Inc. 78Copyright © 2014 All Rights Reserved
    79. 79. Appeal Rights ALJ Hearing If at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration The facility must also send a notice of the ALJ hearing request to the QIC and verify this on the hearing request form or in the written request Harmony Healthcare International, Inc. 79Copyright © 2014 All Rights Reserved
    80. 80. Harmony Healthcare International ADR Response And Appeal Packages Harmony Healthcare International, Inc. 80Copyright © 2014 All Rights Reserved
    81. 81. Additional Development Requests Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 81
    82. 82. Additional Development Requests Medicare Contractors send providers additional development request (ADR) letters requesting additional documentation The ADR letters will be mailed and /or the claim in question will be in status location S B6001 that identifies claims in FISS that are in an ADR status/location Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 82
    83. 83. Additional Development Requests Do not submit replacement/duplicate claims for the ones pending in medical review The submission of replacement/duplicate claims will result in claim denial, rejection or recoupment This will p r o l o n g the medical review process Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 83
    84. 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. 85. Additional Development Requests After the 45th day, if the documentation needed to make a medical determination is not received, the claim may be denied as records not received timely and these claim denials are issued with Remittance Advice Code N102/56900 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 85
    86. 86. Additional Development Requests CMS guidelines allow contractors the time frame of 60 days to complete the review from the date on which the last of the requested medical records is received Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 86
    87. 87. Harmony Healthcare International The Appeal Harmony Healthcare International, Inc. 87Copyright © 2014 All Rights Reserved
    88. 88. The Appeal Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 88 Assign a team leader to oversee the preparation of the denial package Work as a team to gather pertinent information for the Medicare Appeal Review the medical record to ensure completeness
    89. 89. The Appeal It is important to read the ADR or denial letter thoroughly as the letters will assist the facility in gathering the appropriate information Review the list of items provided in the decision statement to include in the medical record Consider additional info not listed that will support the services provided Harmony Healthcare International, Inc. 89Copyright © 2014 All Rights Reserved
    90. 90. Monitor the Appeal Internal tracking system to monitor When ADR or denial was received When package was sent out Final results of the review Harmony Healthcare International, Inc. 90Copyright © 2014 All Rights Reserved
    91. 91. The Appeal In order to effectively manage a Medicare denial, the facility must work as a team to gather pertinent information Assign a team leader to oversee the preparation of the denial package All members of the team should review the medical record to ensure completeness Harmony Healthcare International, Inc. 91Copyright © 2014 All Rights Reserved
    92. 92. The Appeal The following team members are beneficial in this process: MDS Coordinator Director of Nursing Unit Managers (consider) Restorative Nursing program Manager Director of Therapy Any therapy professionals involved in the patient’s care Social Services Dietary Additional team members who participated in care Harmony Healthcare International, Inc. 92Copyright © 2014 All Rights Reserved
    93. 93. The Appeal It is important to read the ADR or denial letter thoroughly as the letters will assist the facility in gathering the appropriate information Review the list of items listed in the ADR/decision statement to include in the medical record Consider additional info not listed that will support the services provided Harmony Healthcare International, Inc. 93Copyright © 2014 All Rights Reserved
    94. 94. ADR/Help Letter Checklist Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 94 HELP LETTER REVIEW CHECK LIST Period Skilled Nursing Chart Review: From: __________________ To: _________________ Medicare Admission Date: ___________ Diagnosis: ________________________________ MDS Reference Dates Review 5 day 14 day 30 day 60 day 90 day SOT/EOT OMRA ARD Billing Dates RUG/HIPPS COT COT COT COT COT COT ARD Billing Dates RUG/HIPPS ICD-9 Codes ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
    95. 95. The Appeal Package List of items typically requested: Initial MDS and any MDS that corresponds to the billed dates of service and look back All physician documentation for dates of service in question Physician’s orders MD certifications MD progress notes History and Physical Harmony Healthcare International, Inc. 95Copyright © 2014 All Rights Reserved
    96. 96. The Appeal Package Important to know the consequences if the facility does not submit all necessary paperwork Facility needs to review the packet carefully to avoid a technical denial based on missing information including signatures Harmony Healthcare International, Inc. 96Copyright © 2014 All Rights Reserved
    97. 97. The Appeal Package Each team member should review the package as a whole The team leader should have a final look prior to submitting the appeal PREP Letter Proper Reimbursement Explanation Paper Always keep a copy of the packet sent to the reviewing agency Harmony Healthcare International, Inc. 97Copyright © 2014 All Rights Reserved
    98. 98. Appeals Process PREP Include a statement of position letter with the medical record documentation to the reviewing agency explaining the services provided to the patient Harmony Healthcare International, Inc. 98Copyright © 2014 All Rights Reserved
    99. 99. Monitor the Appeal Harmony Healthcare International, Inc. 99Copyright © 2014 All Rights Reserved
    100. 100. Monitor the Appeal Internal tracking system to monitor When ADR or denial was received When package was sent out Final results of the review Harmony Healthcare International, Inc. 100Copyright © 2014 All Rights Reserved
    101. 101. Harmony Healthcare International Redetermination and Reconsideration Harmony Healthcare International, Inc. 101Copyright © 2014 All Rights Reserved
    102. 102. Redetermination and Reconsideration If a claim is initially denied, there is action the facility can take The first stage is the Redetermination The next step is a Reconsideration Harmony Healthcare International, Inc. 102Copyright © 2014 All Rights Reserved
    103. 103. Redetermination An examination of a claim by a review agency who is different from the agency who made the initial determination The facility has 120 days from the date of receipt of the initial claim determination to file an appeal A minimum monetary threshold is not required to request a determination Harmony Healthcare International, Inc. 103Copyright © 2014 All Rights Reserved
    104. 104. Redetermination Include an appeal letter that outlines the argument for coverage Brief explanation of the hospitalization (if one occurred) Past medical history Status of patient on admission List of the skilled nursing services provided to the patient Harmony Healthcare International, Inc. 104Copyright © 2014 All Rights Reserved
    105. 105. Redetermination Appeal Letter An explanation of skilled therapy services provided to the patient Medicare guidelines used in the skilled care decision making process, if applicable Harmony Healthcare International, Inc. 105Copyright © 2014 All Rights Reserved
    106. 106. Redetermination Any additional supporting documentation not submitted during the Help letter phase from the medical record should be submitted along with the redetermination request Highlight Add sticky tabs The redetermination request should be sent to the contractor that issued the initial determination Harmony Healthcare International, Inc. 106Copyright © 2014 All Rights Reserved
    107. 107. Redetermination Contractors will generally issue a decision within 60 days of receipt of redetermination request in the form of : A letter A Medicare Redetermination Notice (MRN) Revised remittance advice Harmony Healthcare International, Inc. 107Copyright © 2014 All Rights Reserved
    108. 108. Reconsideration If the request for redetermination results in a denial, a reconsideration can be requested A QIC will conduct the reconsideration request The QIC reconsideration process allows for an independent review of medical necessity by a panel of physicians or other health-care professions A minimum monetary threshold is not required to request a reconsideration Harmony Healthcare International, Inc. 108Copyright © 2014 All Rights Reserved
    109. 109. Reconsideration A written reconsideration request must be filed within 180 days of receipt of the redetermination Instructions are provided on the Medicare Redetermination Notice (MRN) A Request for reconsideration may be made on Form CMS-20033. This form will be mailed with the MRN Harmony Healthcare International, Inc. 109Copyright © 2014 All Rights Reserved
    110. 110. Reconsideration Include a letter outlining the argument for payment The request should clearly explain why the facility disagrees with the redetermination A copy of the MRN, and any other supportive documentation, should be sent with the reconsideration request to the QIC identified in the MRN Harmony Healthcare International, Inc. 110Copyright © 2014 All Rights Reserved
    111. 111. Reconsideration Reconsiderations are conducted on-the- record; and in most cases, the QIC will send its decision to all parties within 60 days of receipt of the request for reconsideration The decision will contain detailed info on further appeal rights if the decision is not fully favorable Harmony Healthcare International, Inc. 111Copyright © 2014 All Rights Reserved
    112. 112. Reconsideration If the QIC cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to an ALJ Harmony Healthcare International, Inc. 112Copyright © 2014 All Rights Reserved
    113. 113. A Successful ALJ Hearing Harmony Healthcare International, Inc. 113Copyright © 2014 All Rights Reserved
    114. 114. ALJ Overview After the redetermination and reconsideration process, if at least $130 remains in controversy following the QIC’s decision, the facility may request an ALJ hearing within 60 days of receipt of the reconsideration The facility must send a notice of the ALJ hearing request to the QIC on the hearing request form or in the written request Harmony Healthcare International, Inc. 114Copyright © 2014 All Rights Reserved
    115. 115. ALJ Overview A letter to request the ALJ hearing should simply highlight the most pertinent reasons justifying payment Harmony Healthcare International, Inc. 115Copyright © 2014 All Rights Reserved
    116. 116. ALJ Overview ALJ hearings are generally held by video-teleconference (VTC) or by telephone If the facility prefers not to have a VTC or telephone hearing, they may ask for an in-person hearing, but they must demonstrate the necessity for an in- person hearing Harmony Healthcare International, Inc. 116Copyright © 2014 All Rights Reserved
    117. 117. ALJ Overview The ALJ will determine whether an in- person hearing is warranted on a case-by- case basis Facilities may also ask the ALJ to make a decision without a hearing (on-the- record). CMS or its contractors may participate in an ALJ hearing, but they must provide notice to the ALJ and all parties of the hearing Harmony Healthcare International, Inc. 117Copyright © 2014 All Rights Reserved
    118. 118. ALJ Overview ALJ will generally issue a decision within 90 days of receipt of the hearing request The timeframe may be extended for a variety of reasons including, but not limited to: The case being escalated from the reconsideration level The submission of additional evidence not included with the hearing request The request for an in-person hearing The facility’s failure to send notice of the hearing request to other parties and The initiation of discovery if CMS is a party Harmony Healthcare International, Inc. 118Copyright © 2014 All Rights Reserved
    119. 119. ALJ Overview If the ALJ does not issue a decision within the applicable timeframe, you may ask the ALJ to escalate the case to the Appeals Council level Harmony Healthcare International, Inc. 119Copyright © 2014 All Rights Reserved
    120. 120. ALJ Hearing Preparation Harmony Healthcare International, Inc. 120Copyright © 2014 All Rights Reserved
    121. 121. ALJ Office of Medicare Hearings and Appeals (OHMA) Administrative law judge hearings will not be assigned to a judge for at least two years OMHA stopped assigning new hearing requests from providers as of July 15, 2013 The weekly influx of hearing requests surged from an average of 1,250 in January 2012 to more than 15,000 in December 2013 Medicare Appellant Forum to provide updates to OMHA appellants on the status of OMHA operations http://www.hhs.gov/omha/omha_medicare_appellant_for um.html Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 121
    122. 122. ALJ Hearing Preparation Appeal Process Discuss and study CMS Guidelines Discuss type of ALJ hearing (video, phone, in person) to anticipate the format Goals of the Hearing Inform the Judge of skilled services Get the claim paid Harmony Healthcare International, Inc. 122Copyright © 2014 All Rights Reserved
    123. 123. ALJ Hearing Preparation Team Preparation Medical record review Outline of speaking points Select a point person for the hearing Team input Harmony Healthcare International, Inc. 123Copyright © 2014 All Rights Reserved
    124. 124. ALJ Hearing Hearing Process Prepare the facility designated hearing room for video or phone hearings Judge’s assistant will initiate the phone contact (test phone lines and speakers) Introductions Statement by facility Offer to fax any pertinent documents discussed during the hearing Harmony Healthcare International, Inc. 124Copyright © 2014 All Rights Reserved
    125. 125. ALJ Hearing Organize documentation Keep pertinent notes or forms at your finger tips Number the pages for reference Have the staff that worked with patient on the call Speak respectfully, clearly, slowly Provide a concise summary Harmony Healthcare International, Inc. 125Copyright © 2014 All Rights Reserved
    126. 126. ALJ Hearing Be prepared to answer questions prepared by the Judge Why did the patient require skilled therapy when they were hospitalized for a UTI? Where does the medical record state that continued therapy services were necessary after the initial date in question? Explain why skilled care continued although the notes indicate the patient did not have an exacerbation of medical condition? Harmony Healthcare International, Inc. 126Copyright © 2014 All Rights Reserved
    127. 127. ALJ Hearing Be prepared to answer questions asked by the Judge When did the patient get discharged from therapy services? Why do the daily nursing notes state the patient was ambulating ad lib, yet physical therapy continued to provide skilled treatment? Harmony Healthcare International, Inc. 127Copyright © 2014 All Rights Reserved
    128. 128. Conclusion Educate, Discuss and Prepare Don’t Wait for Medicare Medical Review Communicate to all Staff Medicare Skilled Care Criteria Refine Interdisciplinary Management of Medicare Appeals Establish and Maintain Peer Review and External Review of Records to Assure Insulation of Claims Harmony Healthcare International, Inc. 128Copyright © 2014 All Rights Reserved
    129. 129. Keys to Success Provide clinically appropriate care Document Medical necessity Deficits Outcomes Meet technical requirements Review entire medical record Respond to ADRs timely Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 129
    130. 130. Questions/Answers Harmony Healthcare International (978) 887 - 8919 www.Harmony-Healthcare.com Cmullin@Harmony-Healthcare.com @KrisMastrangelo @Harmonyhlthcare facebook.com/HarmonyHealthcareInternational H linkedin.com/company/harmony-healthcare Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 130
    131. 131. Copyright © 2014 All Rights Reserved Register online http://info.harmony-healthcare.com/harmony2014 or by phone (978) 887-8919 ext. 13 Register Online Harmony Healthcare International, Inc. 131
    132. 132. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 132
    133. 133. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 133

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