Medicare Denied Claims: How the Appeal Letter Can Make or Break You

Medicare Denied Claims – How the
Appeal Letter Can Make or Break You
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. (HHI)
Presented by:
Carrie Mullin, OTR/L, RAC-CT
Claims Review Specialist

About Caroline
Claims Review Specialist for Harmony Healthcare
International, Inc.
MS OTR/L, RAC-CT
Experience:
Extensive history with long term care as an
Occupational Therapist, Director of Rehabilitation,
and as Regional/Corporate Consultant for
Harmony Healthcare.
Specialized in working with facilities on preparing
medical records for ADRs and appeals, as well as
assisted facilities in preparation for ALJ hearings.
Partnered with law firms to assist facilities with
both internal and OIG investigations.
Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc.
2

Objectives
Learner will be able to summarize goals of
Medicare Medical Review
Learner will be able to identify and articulate
examples of documentation to support skilled
nursing and rehabilitative care in the SNF
Learner will be able to identify strategies for
interdisciplinary management of Medicare
appeals
Harmony Copyright 2014 All Rights Reserved Healthcare International, Inc. 3

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.”
Harmony Healthcare International, Inc. 4

Medicare Denied Claims – How the Appeal
Letter Can Make or Break You
Know Your Medicare Guidelines
Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 5

PREP Objective
One of the best ways to argue your facility
provided skilled care to a patient is to outline
the services provided and tie each one back
to the Medicare guidelines that support them
Intermediaries tend to use blanket statements
such as, “services were not reasonable and
necessary” or “does not meet SNF care
requirements”

PREP Objective
Your appeal letters should directly
address potential areas for denial at the
Additional Development Request (ADR)
level
Explain how the services provided meet
the definition of medically reasonable
and necessary to stop the process in its
tracks

Technical Denial Reasons
Response to Additional Documentation Request
(ADR) did contain documentation requested
Documentation not received within requested
time frame
Physician Certification not signed or missing
Therapy Billing logs do not support billing
Part A – MDS Assessment
Part B - 8 Minute Rule
Illegible documentation
Hospital documentation was not submitted

Clinical Denial Reasons
Documentation did not support medical
necessity
Documentation does not support daily
skilled intervention by a qualified
therapist
Documentation in the medical records
must support continued progress

Denial Reasons
Services provided were likely clinically
appropriate but the documentation
provided to reviewers did not support:
Technical requirements
Medical necessity
The skills of a therapist were required
Functional outcome
Need to receive an inpatient level of care

Denial 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

Denial Reasons
Skills of a Therapist
ST minutes were reduced based on clinical
judgment because documentation did not
support the billed minutes were reasonable
and necessary. The beneficiary could not
participate in self feeding during this period and
required the speech therapist to assist with 100%
of the feeding.
Documentation did not support medical necessity
and need for continued skilled therapy. Patient
needs assistance and supervision.

Denial 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

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

Denial Reasons
Custodial Level of Care
Example
Skilled rehabilitation and nursing
services were custodial in nature and
could have been met with restorative
nursing, family member, or nursing
provision of intermittent skilled
rehabilitation and nursing services

Denial 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

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

Denial Reasons
Goals
Goals are not functional (i.e., patient
will perform 10 repetitions of upper
extremity exercises with the yellow
theraband)
Duplication of services between
disciplines

Denial Reasons
Lack of Functional Progress
Gains were not significant and there was no
indication of carryover of the functional task
Lack of documentation relating to the patient
having the potential to show significant progress
No significant improvement with functional ability
The outcome of therapy treatment was not
documented
Failure to document a complete treatment plan as
outlined in Documentation Required section

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
Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc.
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Denial Reasons
Modalities
Electrical Stimulation used to treat motor function
disorders, such as multiple sclerosis, is considered
investigational and therefore, non-covered
Electrical Stimulation used in the treatment of facial
nerve paralysis, commonly known as Bell’s Palsy, is
considered investigational and therefore, non-covered
Diathermy and Ultrasound heat treatments for the
treatment of asthma, bronchitis, or any other
pulmonary condition are considered not reasonable
and necessary, and therefore, non-covered

Denial Reasons
Cognitive Therapy
The record documented a diagnosis of
Alzheimer’s disease. SLP documentation
does not support further significant
practical improvement could be expected.
Medical justification for ST services is not
established
Speech treatment cognition for dementia
Poor progress with cognition

Denial 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

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

Documentation to Support
Identified Risk Areas
Identify potential denial risk areas
What might the reviewer have not seen in the
documentation provided to lead the reviewer to deny
services?
What additional documentation may be included to
further support skilled rehabilitation and nursing
services provided?
Consultations/ED Visits
Care Plan
Physician Progress Notes
Social Services/Dietary Notes

What is Skilled Care?
Anchoring the Skill

Medicare Requirements
The patient requires Skilled Nursing
Services or Skilled Rehabilitation
Services (i.e., services that must be
performed by or under the supervision
of professional or technical personnel)
(See §214.1 – 214.3)
Copyright 2014 All Rights Reserved

Medicare Eligibility
Treated for a condition which was
treated during a qualified stay…or…
which arose while in a SNF for a
treatment of condition for which the
beneficiary previously was treated in a
hospital
For Example:
Fractured hip develops pneumonia
secondary to immobility

Medicare Requirements
The patient requires these skilled
services on a daily basis (see
§214.5)
Daily Nursing Notes
Treatment Sheets
Copyright 2014 All Rights Reserved

30
Skilled Rehabilitation
Medicare Benefit Policy Manual Chapter 8
On a daily basis
Services rendered are reasonable and
necessary
MD ordered
Practical matter
An appropriately licensed or certified
individual must provide or directly supervise
the therapeutic service and coordinate the
intervention with nursing services
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Harmony Healthcare International
Medicare Benefit Policy Manual
Chapter 8 Revisions
December 2013

Why Update the Policy Manual?
CMS Settlement
CMS revised the Medicare Benefit Policy
Manual (December 2013) and will revise
other Medicare Manuals to correct
suggestions that Medicare coverage is
dependent on a beneficiary "improving"
New policy provisions state that skilled
nursing and therapy services necessary to
maintain a person's condition can be
covered by Medicare

Medicare Benefit Policy Manual Update
“Coverage for such skilled therapy services does not
turn on the presence or absence of a
beneficiary’s potential for improvement from
therapy services, but rather on the beneficiary’s need
for skilled care. Therapy services are considered
skilled when they are so inherently complex that they
can be safely and effectively performed only by, or
under the supervision of, a qualified therapist. (See
42CFR §409.32) These skilled services may be
necessary to improve the patient’s current condition,
to maintain the patient’s current condition, or to
prevent or slow further deterioration of the
patient’s condition.” - December 2013

Medicare Benefit Policy Manual Update
“The services must be provided with the expectation, based
on the assessment made by the physician of the patient’s
restoration potential, that
The condition of the patient will improve materially in a
reasonable and generally predictable period of time; or,
The services must be necessary for the establishment
of a safe and effective maintenance program; or,
The services must require the skills of a qualified
therapist for the performance of a safe and effective
maintenance program”
– December 2013

RAI User’s Manual Update
RAI User’s Manual September 2013:
Therapy services can include the actual
performance of a maintenance program in those
instances where the skills of a qualified therapist
are needed to accomplish this safely and
effectively
However, when the performance of a maintenance program
does not require the skills of a therapist because it could be
accomplished safely and effectively by the patient or with the
assistance of non-therapists (including unskilled caregivers),
such services are not considered therapy services in this
context

Jimmo v. Sebelius
The Jimmo v. Sebelius case challenged
Medicare's use of an "Improvement
Standard" to make coverage
determinations
The lawsuit was brought on behalf of:
Six individuals representing a Nationwide
class of Medicare beneficiaries
National organizations representing
people with chronic conditions
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 36

Individual Plaintiffs:
Glenda Jimmo
Paul O. Boisvert for New York Times
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc.
37

Individual Plaintiffs
Lead plaintiff, Glenda Jimmo, is a 76-year-old
Medicare beneficiary from Bristol, Vermont
Blind since birth and has had her right leg
amputated due to complications from diabetes
Requires a wheelchair, and receives multiple
home health care visits per week for various
treatments for her complex condition
Medicare denied coverage for these services,
saying that she was unlikely to improve

Individual Plaintiffs:
Rosalie J. Berkowitz
New York Times October 22, 2012
Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc.
39

Individual Plaintiffs
Rosalie J. Berkowitz is an 81-year-old
Medicare beneficiary from Stamford,
Connecticut
Multiple Sclerosis
Medicare denied coverage for home health
visits and physical therapy on the grounds
that her condition was not improving
Her family said she would have to go into a
nursing home if Medicare did not cover the
services

National Organizations
National Multiple Sclerosis Society
Parkinson’s Action Network
Paralyzed Veterans of America
Alzheimer’s Association
United Cerebral Palsy
National Committee to Preserve Social
Security and Medicare, an advocacy
group

Improvement Standard
The settlement addresses Medicare
terminating or denying coverage to
beneficiaries who are not improving for
Medicare Part A and Part B

Plaintiffs alleged the “Improvement Standard”:
Is "a covert rule of thumb" that is not
supported by the Medicare statute or
regulations
Operates as an additional condition of
eligibility which effectively denies
beneficiaries coverage of certain skilled
services

According to the Complaint, Medicare has:
Failed to make assessments regarding a
beneficiary's "unique condition and individual
needs"
Does not rely on the Medicare statute,
regulations and manuals, but relies on
"more restrictive internal guidelines,
policies, and Local Coverage
Determinations (LCDs)”

CMS Settlement
Attorneys from the Center for Medicare
Advocacy, Vermont Legal Aid and the
Centers for Medicare & Medicaid Services
(CMS) have agreed to settle the
"Improvement Standard" case, Jimmo v.
Sebelius
A proposed settlement agreement was filed in
Federal District Court on October 16, 2012
The Settlement was approved on January
24, 2013
Harmony Copyright © 2014 All Rights Reserved Healthcare International, Inc. 45

Jimmo v. Sebelius
The judgment indicates that as long as
a patient requires skills of a therapist
or a nurse, a patient would meet the
skilled coverage criteria despite not
making functional gains
Documentation must support the need
for skilled therapy intervention

Know Your Reviewer

Medicare Administrative
Contractors

Medicare Administrative Contractors
2003 mandated that the Secretary of
Health & Human Services replace Part
A FIs and Part B carriers with Medicare
Administrative Contractors (MACs).
CMS established MACs as multi-state,
regional contractors responsible for
administering both Medicare Part A and
Medicare Part B claims.

CMS relies on a network of MACs to
process Medicare claims, and MACs
serve as the primary operational contact
between the Medicare Fee-For-Service
program, and approximately 1.5 million
health care providers enrolled in the
program

Collectively, the MACs and the other
Medicare claims administration
contractors process nearly 4.9 million
Medicare claims each business day,
and disburse more than $365 billion
annually in program payments

Centers for Medicare & Medicaid
Services (CMS) contracts with Medicare
Administrative Contractors (MACs) to
assist with local claims processing and
the first level appeals adjudication
function

Under probe reviews, contractors may
examine 20-40 claims per provider for
provider-specific problems
Contractors also conduct widespread
probe reviews (involving approx. 100
claims) when a larger problem, such as
a spike in billing for a specific
procedure, is identified

Section 521 of the Medicare, Medicaid, and
SCHIP Benefits Improvement and Protection
Act of 2000 (BIPA) included provision aimed
at improving the Medicare fee-for-service
appeals process
Part of the provisions mandate that all
second-level appeals (for both Part A and
Part B), also known as reconsiderations, be
conducted by Qualified Independent
Contractors (QICs)

Recovery Audit Contractors

The Recovery Auditors Program Mission
The Recovery Auditor detects and corrects
past improper payments so that CMS can
implement actions that will prevent future
improper payments:
Providers can avoid submitting claims that do
not comply with Medicare rules
CMS can lower its error rate
Taxpayers and future Medicare beneficiaries
are protected

If you bill fee-for-service programs,
your claims will be subject to review
by the Recovery Auditors
Target areas are posted on the
RACs’ websites

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

The appeal process for Recovery Audit denials
is the same as the appeal process for
Carrier/FI/MAC denials
“Discussion Period” by phone in the first 15
days of denial
If you disagree with the Recovery Auditor’s
determination:
File within 30 days to avoid recoupment
Up to 120 days to appeal
Interest will still accrue during the appeal process

ZPIC Audit

Frequency of Medical Review
Significant increase in frequency of
Medical Review
Office of Inspector General (OIG) Reports
Department of Justice (DOJ) Review
Zone Program Integrity Contractor (ZPIC)
Recovery Audit Contractor (RAC)
Budget cuts
Expect to be Reviewed

Insulate, Insulate, Insulate!!!
Zone Program Integrity Contractor
(ZPIC)
CMS launched another major initiative to target
providers other than the hospital setting as the
RAC auditors have been focusing on hospital
audits
Southeast, South Central, Midwest, Northeast
and West Coast regions of the U.S. are
seeing the most ZPIC audits at this time

Zone Program Integrity Contractor
(ZPIC)
ZPICs
SafeGuard Services
AdvanceMed
Health Integrity
Integriguard
Surprise on-site visits
Targeted data analysis
Random audits
100% pre-payment holds

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

ZPIC Audits
ZPIC targets are often selected based on
Unusual trends or changes in utilization over time
Specific schemes noted by CMS that
inappropriately maximize generated
reimbursement
Referrals from law enforcement and other sources
for possible fraud and abuse
High volume or high cost services that appear like
they are being over-utilized

ZPIC Audit Targets
Providers with patients having unusually long lengths
of service or high case mix levels
HHAs with patients having extended numbers of
visits
Hospice providers with high length-of-stay patients
A SNF with a large volume of high “RUG” level claims
Disgruntled employee who threatened you as a
“whistleblower”
Operators in areas identified as high risk for fraud
(Miami-Dade and Broward Counties)

ZPIC Audits
ZPICs are specifically allowed to
Place you on pre-payment review
The pre-payment review flag remains until a
determination is issued on the audit, which
can take a long time
Place you on billing suspension
Withhold payments

ZPIC Audits: What auditors demand at
an unscheduled visit
Require proof that you are operating at the
identified practice locations
Interview your staff
Required documentation that you meet
conditions of participation
Submit a request for records, including:
Business records
Medical records
Members of law enforcement can accompany
ZPIC auditors

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

Review Audits
Rehab and MDS Questions
Sample therapy staff interview
questions:
1. Do you feel pressure to meet your RUG
levels?
2. Who has the say on discharge from
therapy?

Review Audits
Sample MDS staff interview questions:
1. Who decides the ARD?
2. Do they provide group and concurrent
treatments?

Comprehensive Error Rate Testing
(CERT)

CERT Audits
CERT program monitors payments made by
the MAC to the SNF
Each year, CERT evaluates a statistically
valid random sample of claims to determine if
they were paid properly under Medicare
coverage, coding, and billing rules

CERT Process
Claim Selection
Medical Record Requests
Review of Claims
Assignment of Improper Payment
Categories
Calculation of the Improper Payment
Rate

CERT Process
A stratified random sample is taken by
claim type: Part A and Part B
Claims are selected on a semi-monthly
basis
The final CERT sample is comprised of
claims that were either paid or denied
by the MACs

CERT Process
The CERT Documentation contractor requests
medical records from the provider or supplier that
submitted the claim
If no documentation is received within 75 days of the
initial request, the claim is classified as a “no
documentation” claim and counted as an error
If documentation is received after 75 days of the
initial request (late documentation), CERT will still
review the claim

CERT Process
Reviews are conducted by nurses, medical
doctors, and certified coders review the
claims
Determinations are made regarding whether
the claim was paid properly under Medicare
coverage, coding, and billing rules
Improper payment categories are assigned

CERT Audits
Therapy Documentation:
Missing/incomplete plan of care/treatment
plan;
Missing Physician/Non-Physician
Practitioner (NPP) signatures and dates;
Missing total time for procedures and
modalities; and
Missing certification and recertification.

CERT Process
Improper Payment Categories
No Documentation
Insufficient Documentation
Medical Necessity
Incorrect Coding
Other

CERT Outcomes
If the error rate appears high, corrective
actions can be put into place
Error Rate Reduction Plans
Allocate additional funds for representation
at Administrative Law Judge (ALJ)
hearings
Allocate additional funds to the MACs to
increase their prepayment review on
error-prone claim types
Educational programs for providers

PREP Objective
Each auditing agency has a slightly different
agenda. Understand what their goals are.
Most auditing agencies hire nurses,
therapists, and coding experts to review
medical records
If your reviewer is a nurse or a coding expert,
they may not see the skilled services the
same way the therapy staff does

PREP Objective
A detailed PREP outlining the skilled services
is imperative
Include definitions of standardized tests used,
explanations of diet textures, details of
specific procedures and techniques
Why a decline should be considered a
“significant decline”?
Assume someone from another discipline
may be reviewing the record and detail the
PREP accordingly

Choose Your Details Wisely

PREP Outline
Outline the argument for coverage
Brief explanation of the hospitalization (if
one occurred)
Past medical history
Status of patient on admission
List of the skilled nursing services provided
to the patient

PREP Outline
Appeal Letter
An explanation of skilled therapy
services provided to the patient
Medicare guidelines used in the
skilled care decision making process,
if applicable

PREP Objective
Start with a basic framework of
background information, daily skilled
nursing services, and gains made in
therapy.
Tie services back to the hospitalization
Tie services to conditions that arose in the
SNF

PREP Objective
If there are no concrete gains made in
therapy (i.e. progress from one level of
assist to another), ensure additional
details of another measureable benefit
are included.
Be detailed! Consider the likely reasons
for denial and address them head on.

Skills of a Therapist or a Nurse
Services must require the expertise, knowledge,
clinical judgment, decision making and abilities of a
therapist or a nurse that qualified personnel, trained
caretakers or the patient cannot provide
independently

Skills of a Therapist or a Nurse
Documentation must support:
Description of skilled treatment
Changes made to the plan of care
due to assessment of the patient’s
needs
Medical complexity
Why the clinical and critical thinking of
a therapist or a nurse are required

Why is this material important?
Which team members should be aware
of the Medicare Skilled Care criteria?
How often will this criteria be relevant to
current beneficiaries and applicable for
denied claims?

Requires the skills of qualified technical or
professional health personnel such as RN, LPN, PT,
OT or SLP
Must be provided directly by or under the general
supervision of a licensed nurse or skilled rehab
personnel to assure the safety of the resident and to
achieve the medically desired result
“General supervision” requires initial direction and periodic
inspection of activity
Ordered by a physician
Services are needed and provided on a daily basis

The need for skilled care must be
justified and documented in the medical
record
Conditions may have prompted the
initial hospitalization, but also include
the conditions that arose during
recovery in the SNF

What is Skilled Care ?
Direct Skilled Nursing Services
Management and Evaluation of a Care
Plan
Observation and Assessment
Teaching and Training

Skilled Services Categories:
Inherent Complexity
Inherent Complexity – Direct skilled
nursing services including:
IV feeding
IV meds
Suctioning
Tracheostomy Care
Ventilator support
Ulcers

Inherent Complexity
Inherent Complexity
Tube feedings
Respiratory Therapy 7 days per week
Surgical wound or open lesions with treatments
Unstable clinically with diabetes with injections
Transfusions
Chemotherapy
Colostomy Care, early post-op care

Skilled Observation and Assessment
Reasonable probability or possibility for
complication
Potential for further acute episodes
Identify and evaluate the need for
modification of treatment
Evaluate initiation of additional medical
procedures
Skilled observation can be required until the
treatment regimen is essentially stabilized

Fever
Dehydration
Septicemia
Pneumonia
Nutritional Risk
Chemotherapy
Weight loss
Blood sugar control
Impaired cognition
Severe Mood and
Behavior conditions
Copyright © 2014 All Rights Reserved 97
Harmony Healthcare International, Inc.

Neurological
Respiratory
Cardiac
Circulatory
Pain/Sensation
Nutritional
Gastrointestinal
Genitourinary
Musculoskeletal
Skin

Identify and outline daily skilled nursing
observations and assessments
Record DAILY each itemized area listed
on your outline

If a patient was admitted for skilled
observation but did not develop a further
acute episode or complication, the skilled
observation services still are covered so long
as there was reasonable probability for such
a complication or further acute episode
“Reasonable probability” means that a potential
complication or further acute episode is a likely
possibility

Management and Evaluation of a Care Plan
Based on the physician’s orders, these
services require the involvement of skilled
nursing to meet the resident’s:
Medical needs
Promote recovery
Ensure medical safety

This area includes:
The sum total of unskilled services
Potential for serious complications
High probability of relapse
Recovery and safety
Meet medical needs
Includes resident’s overall condition

Topic Areas to include:
Surgical sites
Circulatory status
Status of fractures
Maintenance of weight-bearing status
Skin Care
Labs
Consultant Recommendations

Although any of the required services could be performed
by a properly instructed person, that person would not
have the capability to understand the relationship among
the services and their effect on each other. Since the
nature of the patient’s condition, his age and his
immobility create a high potential for serious
complications, such an understanding is essential to
assure the patient’s recovery and safety. The
management of this plan of care requires skilled nursing
personnel until the patient’s treatment regimen is
essentially stabilized, even though the individual services
involved are supportive in nature and not require skilled
nursing personnel.

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

Colostomy care
Insulin administration
Prosthesis
management
Catheter care
G-tube feedings
IV access sites
Braces, splints and
orthotics
Wound dressings and
skin treatments
Medication
management
Orthopedic
precautions

107
Medicare Benefit Policy Manual, Chapter 8
On a daily basis
Services rendered are reasonable and
necessary
MD ordered
Practical matter
An appropriately licensed or certified individual
must provide or directly supervise the
therapeutic service and coordinate the
intervention with nursing services

108
Skilled Rehabilitation/
MD Involvement
The service must be ordered by a physician.
The therapy intervention must relate directly
and specifically to an active written treatment
regimen established by the physician after
any needed consultation with the qualified
rehabilitation therapy professional and must
be reasonable and necessary to the
treatment of the beneficiary’s illness or injury

109
Skilled Rehabilitation/
MD Involvement
MD involvement to prevent injuries
Medicare allows the professional
therapist to develop a suggested plan of
treatment and to begin providing
services based on the plan prior to MD
signature
MD signature required before facility
bills Medicare.
MD faxed signatures acceptable

110
Skilled Rehabilitation Overview
Directly related to a written plan of treatment
Requires knowledge/skills/judgment of
qualified professional
Services must be considered under
acceptable standards clinical practice
Expectation of improvement of restorative
potential in a reasonable and predictable
period of time….or….
Establishment of a safe and effective
maintenance program

111
Basic Criteria for Rehabilitation
Services
Must be specifically related to the Physician’s
Treatment Plan
Skill of a qualified therapist must be needed
Treatment plan must expect the patient to
improve
Services must fall within accepted standards
of medical practice and be specific to the
patient
The services must be reasonable and
necessary

Paint the Interdisciplinary Picture

PREP Objective
EXAMPLE: Your medical record may have a
note from the Dietary Department
documenting poor intake, an MD note
referencing low blood sugars, a Braden score
that qualifies the patient as high risk for skin
breakdown, and nursing notes that reflect
encouragement for out of bed activities.

PREP Objective
Your PREP needs to take all of those
elements of the medical record and paint the
interdisciplinary picture of care:
How do all of those items interrelate?
What were the risk factors for not having daily
nursing care?
How does the combination of those services
elevate the patient to a skilled level of care?
Management and evaluation of the Care Plan

To paint an interdisciplinary picture,
you must work as an
interdisciplinary TEAM!

What To Do When You Get An ADR

Help Letters and Appeals
In order to effectively manage a Medicare
Help Letter or denied claim, the facility must
work as a team to gather pertinent
information
Assign a team leader to oversee the
preparation of the ADR/appeal package
All members of the team should review the
medical record to ensure completeness

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

Many times the process starts with an
Additional Development Request (ADR)
These can be triggered by items
specific to the patient, such as:
RUG score
ICD-9 code billed
Widespread probe

It is important to read the ADR or denial
letter thoroughly as the letters will assist
the facility in gathering the appropriate
information
Review the list of items provided in the
decision statement to include in the
medical record
Consider additional info not listed that will
support the services provided

The Appeal Package
List of items typically requested:
Initial MDS and any MDS that corresponds to
the billed dates of service and look back
All physician documentation for dates of service
in question
Physician’s orders
MD certifications
MD progress notes
History and Physical

The Appeal Package
Items to include
Include all information in the medical
record from the look back period
MD re-certifications for skilled stay for
billed dates:
If certification is signed by a NP, be aware that
there may be a request for the facility to submit
an attestation letter verifying no direct or
indirect employment relationship with the SNF

The Appeal Package
Items to include
Pre-admission data
Hospital records that validate a qualifying stay
Daily nurses notes
MDSC notes
Case Manager notes
Care Plan
MAR and TAR

The Appeal Package
Items to include
Documentation of all therapies provided
Evidence of MD supervision
Evaluations
Progress notes and
Therapy billing logs
Any other documentation that relates to the
condition for which services were rendered
that skilled the patient for Medicare Part A
services in the Skilled Nursing Facility

The Appeal Package
Items to include
Diagnostic testing and lab work
Documentation of adjustment to HIPPS codes
resulting from MDS corrections
Signature log for all staff members
documenting in the medical record during the
dates in question, including printed name,
credentials and handwritten signatures

The Appeal Package
Each team member should review the
package as a whole
The team leader should have a final
look prior to submitting the appeal
PREP Letter
Proper Reimbursement Explanation Paper
Always keep a copy of the packet sent
to the reviewing agency

How Does Your Team Measure Up?
Take the Harmony Healthcare International
(HHI) Denied Claims Appeals Process
Proficiency Exam
http://cdn2.hubspot.net/hub/56632/file-
285885026-pdf/DenialGraderWB.pdf

ADR/Help Letter Checklist
HELP LETTER REVIEW CHECK LIST
Period Skilled Nursing Chart Review: From: __________________ To: _________________
Medicare Admission Date: ___________ Diagnosis: ________________________________
MDS Reference Dates Review
5 day 14 day 30 day 60 day 90 day
SOT/EOT
OMRA
ARD
Billing Dates
RUG/HIPPS
COT COT COT COT COT COT
ARD
Billing Dates
RUG/HIPPS
ICD-9 Codes
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

All Medical Records Are Different

PREP Objective
Intermediaries review a record in about 10
minutes, which does not leave much time to
learn and understand your facility’s
documentation techniques
Your PREP is the perfect tool to guide
reviewers through your medical record
Reference specific dates and documents
when describing the skilled care provided
Reference specific page numbers.

Appeals Process
Set up your medical record to tell the story
you want told
Dividers and table of contents
Highlight
Sticky tabs

Appealing Medicare
Denied Claims

Appeal Process
Common practice to receive
communications from Medicare review
agencies requesting proof of skilled
services
Understand the process to manage the
inquiry in a timely and detailed manner
in order to minimize lost revenue

Appeal Process
It is not uncommon for an ADR to
result in the denial of part or all of a
claim
Once an initial claim determination
is made providers have the right to
appeal

Monitor the Appeal
Internal tracking system to monitor
When ADR or denial was received
When package was sent out
Final results of the review

Appeal Rights
Redetermination
A review of the claim by the MAC utilizing
personnel who are different from the
personnel who made the initial
determination
The appellant (individual filing the appeal)
has 120 days from the date of receipt of
initial denial to file an appeal
A minimum monetary threshold is not
required to request a redetermination

Appeal Rights
Reconsideration
If the facility is dissatisfied with result of
redetermination, they may request a
reconsideration
A Qualified Independent Contractor (QIC) will
conduct the reconsideration
The reconsideration process is an independent
review of medical necessity by a panel of
physicians or other health care professionals
A minimum monetary threshold is not required to
request a reconsideration

Appeal Rights
ALJ Hearing
If at least $130 remains in controversy
following the QIC’s decision, the facility
may request an ALJ hearing within 60 days
of receipt of the reconsideration
The facility must also send a notice of the
ALJ hearing request to the QIC and verify
this on the hearing request form or in the
written request

ALJ Overview
After the redetermination and reconsideration
process, if at least $130 remains in
controversy following the QIC’s decision, the
facility may request an ALJ hearing within 60
days of receipt of the reconsideration
Combine claims to reach $130 if necessary
The facility must send a notice of the ALJ
hearing request to the QIC on the hearing
request form or in the written request

ALJ Overview
A letter to request the ALJ hearing
should simply highlight the most
pertinent reasons justifying
payment

In Conclusion
Provide clinically appropriate care
Meet technical requirements
Document
Medical necessity
Deficits
Outcomes
Establish and maintain peer review and
external review of records to assure
insulation of claims

In Conclusion
Raise facility awareness
Function as a TEAM
Communicate and be organized
Review entire medical record
Respond to ADRs timely

Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
cmullin@Harmony-Healthcare.com

Harmony Healthcare International (HHI)
For attending this seminar, you are eligible
for one of the following:
Free PEPPER Analysis
Free RUGS Analysis
Assess your facility against key indicators and national norms.
Contact us at:
RUGS@harmony-healthcare.com
Analysis is cost & obligation free

Register online
Register Online
http://info.harmony-healthcare.com/harmony2014
or by phone (978) 887-8919 ext. 13

Medicare Denied Claims: How the Appeal Letter Can Make or Break You

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