Redetermination / Reconsideration

Overview:

Medicare is the national health insurance program to which individuals are entitled under the Social Security Act. Often Medicare claims are speciously denied. It is the SNF Provider's right to appeal an unwarranted denial. Harmony Healthcare International (HHI) supports facilities in appealing more than 100 claims per year.

In order to appeal a Medicare denied claim, the facility must file a Request for Redetermination with the Medicare Contractor. A Redetermination decision will be issued by the Medicare Contractor usually within one to three months after submitting the request.

HHI provides assistance with organizing the medical record packet for submission to the Medicare Contractor. Information and forms necessary to evaluate the denied case and file a "Request for Redetermination," the first level of administrative appeal, are supplied by HHI Denied Claim experts.  This process involves multiple steps including understanding Medicare Coverage Criteria, intimate review of the medical records to support the claim and preparation of an appeal statement to accompany the medical record documents.

HHI provides insight on this process for the interdisciplinary team to prepare for this level of appeal. The goal of this level of appeal is to provide the Medicare Contractor with clarification of the skilled services provided at the facility in order to reverse the denial decision and return the justifiable payment to the facility.

Potential Risk to Providers:

Medicare Coverage guidelines state: To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel.  A condition that does not ordinarily require skilled services may require them because of special medical complications.

Nursing homes make the first decision as to whether or not the care they provide will be covered by the Medicare program.  Lack of understanding of the above regulations and how they apply to each individual situation can prevent the facility from making accurate coverage decisions as well as preclude the beneficiary from receiving Medicare benefits for which they are entitled.

Facility comprehension is critical for pursuit of reimbursement for services that would otherwise be recouped.

How can Harmony Healthcare International (HHI) help?

HHI Denied Claim Experts:

• Educate on Medicare Coverage guidelines.
• Review the medical record documentation to ensure all pertinent documents are thoroughly completed, support the care provided as well as represent skilled coverage guidelines for the services billed.  
• Prepare a PREP (Proper Reimbursement Explanation Paper) to accompany medical record documents that exemplifies the care provided by the SNF professionals and explains the rational for coverage decisions on behalf of the beneficiary.
• Assist facility Denial Champions in tracking and monitoring all denied claim activity.