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Denial Response: What to Do?

Nearly all home health and hospice agencies will at one time or another experience some form of Medicare Medical Review (MR) CMS Medical Review. Associated with this is that nearly all home health and hospice agencies will have some claims denied by MR.

This event can be daunting. When a denial is received: what to do?

First is take a moment to consider the situation. This includes a review of what the review encompassed, who did the review, and what the results are. Is there a summary of findings? Does it contain a detailed Medical Review result spreadsheet? Is it a pre-payment or overpayment situation? Is there an extrapolation?

Next, assess your agency knowledge level about the response and appeals process. Claims have denied, and you have two choices: appeal or not appeal. Each has its own considerations.

Not appealing denied claims means the billed monies are gone. They will either not be final paid (pre-payment denials) or will be expected to be repaid (post-payment denials) to the Medicare Administrative Contractor.

This is the simplest response. If the denials are reviewed and found to be valid, it is actually expected and incumbent upon the home health or hospice agency not to expect to be paid for the non-covered service.

Keep in mind that even non-payments can offer learning opportunities to assess why the claim was denied and to take action in future to prevent this from recurring.

Not appealing denied claims is the easiest route to take. Of course, some claims may be appealed while others are not. If review of the denial information shows there is some basis to appeal, then the appeals process can be started FFSAppeals.

Here is where agencies may wish to obtain outside assistance. While the process itself is relatively straightforward there are many considerations and questions related to appeals. Some of these include:

  • Do we understand the denials?

  • Do we know the deadline for submission?

  • What is the internal cost to process appeals?

  • What is our cost threshold to file appeals?

  • Are we prepared to see it through to the end—possibly even attending an Administrative Law Judge (ALJ) hearing?

  • Do we possess the regulatory knowledge to generate the appeal?

  • What method do we want to use to file appeals? (esMD, paper, fax, contractor portal)

  • Do we have the available time to process the appeals?

  • Do we need to seek attorney assistance (such as when it involves extrapolation, payment suspension, or possible program termination)?

Appeals take time, resources, and perseverance to have a chance for recovery of the denied funds. This must be balanced with the need to learn the process, integrate the records with applicable rules and regulations, and format this into a valid appeal with a chance of getting paid. Simply stating “We provided the service and deserve to be paid” or “We are a good home health [or hospice] agency and provided care in good faith” are not valid appeal strategies.

Instead, much like the nursing process, appealing claims requires assessment of the issue, developing a plan to respond, generate and implement the appeal, and track and follow-up the response to the appeal. If this is not something that your agency wishes to do, by all means seek help.

This help should be able to explain what your situation is and your options. It should be able to address all levels of appeal (redetermination, reconsideration, ALJ hearing attendance, Medicare Appeals Council filings, etc.). It should be consultative with findings so future prevention and staff education can occur. It should be cost effective in relation to the claim.

In addition, you may wish to clarify what level of involvement this assistance will provide: complete appeals or tell you what needs to be in appeals? Can this help provide statistical expert resources (if needed due to extrapolation findings)? If hearings are needed, will the assistance attend with your agency, be expert witness, or attend as your representative if you desire?

Note that no consultant can validly guarantee success with appeals. Many variables affect this: a good consultant should be able to explain these to your satisfaction. Of course the best outcome is payment at lower level appeals, although statistically for non-technical denials (i.e., arguing over medical necessity for home health, or terminal prognosis for hospice) the odds are still not in your favor. For many claims, getting a hearing offers the best chance for success—although no prior step can be omitted to get a hearing.

The best option is for agencies to file all levels of appeal showing actual content from the record linked to applicable rules and regulations leading to and supporting a conclusion for payment. This is where the content of the original charting is key since what was originally placed in the record forms the basis of the case file.

By bringing together, and bringing to the attention of the Medicare Administrative Contractor, Qualified Independent Contractor, or Administrative Law Judge, the clinical record and how it meets the actual Medicare requirements you are on the right track with any appeals. Your agency deserves nothing less.

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