This issue of Medicare Minute discusses appealing denied claims. Often times the business office will receive notification that a claim has not been payed.
You should begin by asking the following questions:
- Are they Medicare Part A or are they Medicare Part B?
- What types of claims are being denied? You need to do an analysis first if you have determined that there are claims that are not being paid by Medicare.
- What is the reason that the claim is being denied?
- Is there a pattern of the type of claims that they are pulling?
- Example patterns of denied claims include: Medicare Part B claims that are include speech therapy? Or Medicare Part A claims that are being billed for services provided at the ultra high level of care?
These questions are to identify the type of denied claims and if there is a cluster or pattern. At the beginning of this process, Medicare sends an additional development request. This is the first step in review of medical claims that have been billed to Medicare. Once a facility has received an additional development request, there should be a team assembled to manage the submission of these documents. Once the team is assembled and you have a person who is going to spear head this team and is going to organize how you will manage your claims, you need to make sure that everyone has an assignment on the team.
- Who is going to pull the records together?
- Who is going to review to make sure every document is in the medical records?
- Who from nursing will review the nursing documentation if there is any?
- Who is going to review therapy, if there is any?
- Who is going to review the bill?
Every team member needs to know what their role is. Next, you file your additional development requests. Please note this is not a denied claim. At this point it is a help letter, which is another term that is utilized. A “help letter” is to make sure that every I is dotted and every T is crossed in regards to providing the reviewer with all of the information they need to assure that Medicare payment was made accurately.
In the case that a claim is denied following the ADR process, once you have sent an additional development request and the claim has been denied then you look at the reasons it was denied and how your team can proceed to appeal. There are resources on the CMS website which provide insight into appealing denied claims and Medicare has posted a brochure on appealing denied claims. If these resources are not enough there are many types of agencies, including Harmony, that work with facilities specifically to address how to minimize denied claims and what to do once your claim is denied. Once a facility beings to receive notices or denied claims, it is essential to assemble your team, look for patterns and track every time you have corresponded with your Medicare Administrative Contractor or Intermediary on filing appeals. There needs to be a timeline of when you send documentation and a copy of anything that has been sent.
Questions about this process?? Contact the HHI experts.