Medicare Denied Claims Management


It is no longer uncommon for facilities to receive communications from Medicare review agencies requesting proof of skilled services.  It is in the best interest of facilities to understand the review process to foster organization and manage inquiries in a timely, detailed manner in order to minimize recoupment of Revenue. 

The goal of the Harmony Healthcare International (HHI) Denial Management service is to assist facilities in appealing notices of denial of payment, as well as to keep all SNF providers informed of any changes in the Medicare system.

HHI assists facilities in understanding the various types of denials and levels of appeal. HHI provides education on Guidelines, Regulations, and recommended systems for ensuring the appropriate response while optimizing the likelihood of obtaining reimbursement for the services provided.

Potential Risk to Providers:

In order to effectively manage a denied Medicare claim, the facility must work as a team to gather pertinent information.  The facility should assign a team leader to oversee the denial package and then all members of the team should review the medical record to ensure their pieces of the puzzle are present and complete.

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

Many times the process starts with an Additional Development Request (ADR).  These can be triggered by items specific to the patient, such as the RUG score or ICD-9 code billed, or they can be part of a wide spread probe.  Under probe reviews, contractors may examine 20 – 40 claims per provider for provider-specific problems.  Contractors also conduct widespread probe reviews (involving approximately 100 claims) when a larger problem, such as a spike in billing for a specific procedure, is identified.

It has become a common occurrence for an ADR to result in the denial of part or all of a claim.  Once an initial claim determination is made, providers, participating physicians and other suppliers have the right to appeal. All appeal requests must be made in writing.

Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) included provisions aimed at improving the Medicare fee-for-service appeals process. Part of these 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).

Medicare offers five levels in the Part A and Part B appeals process. The levels, listed in order, are:

  • Redetermination by a MAC

  • Reconsideration by a QIC

  • Hearing by an Administrative Law Judge (ALJ)

  • Review by the Medicare Appeals Council within the Departmental Appeals Board, (hereinafter "the Appeals Council")

  • Judicial review in U.S. District Court

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