Mitigating The Impact Of Denials
Medicare denials can be
frustrating and costly, but there are proactive steps that providers can take to avoid rejection. Proven strategies to mitigate denial risk were discussed in a Sept. 19 webinar led by Emily Morgan, Director of Appeals and Denials for Kindred Hospital Rehabilitation Services, and Dr. Rodney Thorley, Medical Director at Mercy Rehabilitation Hospital St. Louis. The entire webinar can be accessed at www.modernhealthcare. com/MitigatingImpact.
Medicare reviews are inevitable
CMS is engaged in several ongoing reviews of Medicare claims, including prepayment and post-payment claims, with some going back as many as three years. It’s not uncommon for a facility to have multiple reviewers requesting records on different types of claims. Reviewers may be looking at any number of factors, including admission diagnoses, discharge rates, readmission rates and length of stay. Look at your PEPPER report to see how you compare to your neighbors, your region and the nation at large.
Don’t let reviews slip through the cracks
Create a team of people who are alerted when review notices are received. While some notices may come through your billing system, others are sent to specific executives. Formulate a plan for how those leaders should handle it. If your facility is owned by a larger corporation, set up a plan for how requests sent to your parent company will be communicated.
Pay attention to “magic language,” timestamps and other risk factors
In Kindred’s experience, reviewers look for stated words like “admit to rehab,” the discharge destination on pre-admission screenings, medical prognosis on the initial plan of treatment, current and prior level of function on the post-admission physician evaluation (PAPE), and any barriers expressed during the team conference. They often consider the document complete only when it’s signed, dated and timed. The admission order must have been signed before evaluations are initiated, and the PAPE must be signed within 24 hours.
Audit your documentation
It’s important to regularly review your documentation and ensure it meets CMS criteria. Does it support a beneficiary’s need for admission and ongoing care? Does it support their medical necessity of receiving care in an inpatient hospital program? The latter is an important question: if a patient is in an Inpatient Rehab Facility (IRF), the documentation must make a convincing case that this setting was better for the patient than a skilled nursing facility, an outpatient rehab facility or home health.
If faced with a denial, have a strategy for appeal
Address the specific reasons for the denial, and copy the CMS language or definitions as needed. Reference the IRF Patient Assessment Instrument manual, explaining how you followed those steps and emphasizing medical necessity at admission and at key points throughout the stay. Highlight physician documentation, making sure to distinguish why it was important for the patient to receive care at the IRF level as opposed to lower levels of care.