Harmony Healthcare Blog

Five Fundamental Steps for A Denial Free Medicare Audit

Posted by The Harmony Team on Thu, Jul 07, 2016

audit.jpgProbe, ZPIC, RAC auditors as well as other Medicare Medical Review auditors are quite active throughout the country reviewing PPS and Medicare Part B claims at skilled nursing facility sites.  The request for medical records whether paper or electronic can be a daunting task for providers. Precision and timing are of the essence for a successful review.  CMS considers medical review contractors as being responsible for detecting, deterring, and even preventing Medicare fraud and abuse.  In this capacity, the auditor is directly responsible for operating areas such as investigation, case development, administrative solutions, and referral to law enforcement. 

Providers can take a few simple steps to proactively prepare for ADRs (additional development requests) or respond to claims denials when the team opines to the contrary. 

5 Steps to be Denial Free

  1. Communication – Timing is everything. Expeditiously notify all team members when an Additional Development Request or Unfavorable Notice of Determination is received. Incorporate discussions regarding claim status into an existing meeting so involved team members are updated regularly.
  2. Policy and Process – Establish a facility protocol for managing all requests and appeals. Sign off sheets for Directors and managers to confirm participation in the process are highly recommended.
  3. Organization – Submit documentation and files that are numbered, paginated and provide a table of contents for the location of each piece of data. Check lists for inclusion of all necessary data will assist with this step in the process. Keep a copy of all documents that are submitted at every step of the appeal process.
  4. Champions – Select a point person to be your facility “champion” who can assist with the orchestration of all medical record submissions. Alert: Don’t be late!  Late submissions = DENIALS.
  5. Track the Progress – Read all correspondence received from the Medicare Contactors. Keep a tracking sheet of all dates that there is communication verbal or written regarding each individual claim. 

Are you a provider who is under a review involving multiple claims or receiving monthly requests to submit claims for review?  Harmony Healthcare International recommends researching the claims in question to identify any emerging patterns.  The results from this investigation can further support the facility in instituting education and training that is focused and directed. Take into consideration the determination decisions and explore further actions to address findings which are based on the content of the medical record.  It is imperative staff understand how documentation supports daily skilled care provided by both nursing and therapies.  Above all, the record must reflect each service coded on the MDS and billed on the UB-04

Providers cannot afford to be remiss on charting of care provided to patients accessing Medicare benefits.  Frequent training and reminders to staff regarding the accountability for written reports on each patient can prevent take backs from Medicare Contractors and insulate the Revenue generated for skilled care provided.

If you have questions or concerns about Medicare Denials, please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413. 

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Topics: Medical Record Review, Audits,, Denials

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