If further information is needed to support a claim, a facility will receive an additional documentation request (ADR). The medical record documentation that the facility submits to the requesting party is critical, as well as the timeframe for submitting the information. ADRs may come from several different “review contractors,” and it is important for providers to understand the differences in their roles and purposes.
CERT contractors calculate improper payment error rates, using a stratified random sample of claims. The medical record documentation is reviewed to determine if the claim was properly paid.
MACs will use rates from the CERT Program and the Recovery Audit Program to determine where gaps or vulnerabilities exist, to mitigate future issues. This may include targeted education, pre-payment or post-payment reviews, and new or local coverage determinations.
The Centers for Medicare and Medicaid (CMS) use the Recovery Audit Program as well as MAC and CERT contractors to help prevent improper payments and protect the Medicare Trust Fund.
RACs conduct pre-payment and post-payment reviews of claims where the possibility of improper payment is high. As of August 18, 2023, skilled nursing facilities (SNFs) reason codes and statements for denials could include:
• Insufficient documentation to support a qualifying 3-day inpatient hospital stay • Patient was not readmitted within 30 days of hospital stay • There are no benefit days available • The certification and recertification were not properly completed • The advanced beneficiary notice was found to be invalid • The therapy evaluation was insufficient • Medical records did not support medical necessity
The UPIC is a recovery contractor of a more serious nature, and is notified by other auditing agencies when facilities make repetitive documentation, coding, or billing errors without corrective action or improvement. The UPIC is responsible for preventing fraud, waste and abuse in Medicare and Medicaid Programs, and therefore has the authority to refer suspicions to the Office of Inspector General (OIG) Office of Investigations (OI). Based on the results of their investigation, the OIG may implement penalties including civil and criminal prosecution, and/or administrative sanctions.
The current SMRC, Noridian Healthcare Solutions, may request medical record reviews for Medicare and Medicaid claims. The SMRC uses data analysis and results from the CERT contractor to select the type of review to conduct. Their focus may include professional organizations, federal oversight agencies, as well as special requests made by CMS.
Facilities should pay particular attention to the documentation requirements under the Patient Driven Payment Model (PDPM). When the reason code used to deny a claim is that the medical record “does not support the level of service as shown on the claim,” this means an item that impacts payment was coded on the Minimum Data Set (MDS) without documentation in the medical record to support that item.
When the auditor finds the documentation is lacking, the claim may be fully or partially denied. The auditor will then categorize the findings as insufficient documentation, failure to support medical necessity, incorrect coding, or various other reasons. Once again, facilities should understand that incorrect coding for a SNF implies an item was coded on the MDS without documentation in the medical record to support the item being coded.
Comprehensive Claims Management
A facility should not take any ADR lightly, and should put forth every effort to ensure the documentation necessary to support the claim is collected timely. Upon receiving a claim denial, the facility has the right to appeal the decision.
It is advisable that the facility take proactive steps to identify gaps in systems and processes to increase compliance and mitigate further claim denials. This can be achieved with Richter’s comprehensive clinical consulting services. We offer: