Mit­i­gat­ing The Im­pact Of De­nials

Modern Healthcare - - NEWS -

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.

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