It is important to understand that the “claim” or UB-04 form is the result of the care and services provided to the Medicare Part A patient. Therefore, the revenue cycle begins at the patient’s admission and continues throughout the Medicare Part A stay. When the medical record does not support what is reported on the Minimum Data Set (MDS), the Health Insurance Prospective Payment System (HIPPS) reported on the claim can be considered incorrect—which may cause the claim to be partially or totally denied.

The denial process begins with an additional documentation request (ADR) that can be received from different review contractors, such as the facility’s Medicare Administrative Contractor (MAC), Comprehensive Error Rate Testing (CERT) contractors, Unified Program Integrity Contractors (UPICs), and Supplemental Medical Review Contractors (SMRC). Facilities must take the request seriously and act timely in providing the documentation. Leaving out a critical document or not compiling the documents in a specific order could lead to a quick denial of the entire claim. 

Once the requested medical record has been reviewed, the auditing agency will send a Medicare Summary Notice (MSN) to the facility and include the decision in the remittance advice as to whether the claim will be paid, or partially or fully denied. Partial denial means the medical record supports some but not all services provided. Whether partially or fully denied, the facility has the right to appeal. 

There are five levels of appeal which occur in the following order:

1. Level one is the request for redetermination by the MAC. The medical record will be reviewed by personnel that were not involved with the initial denial of the claim. Although the facility has 120 days to file the appeal, they should take action as soon as possible. If the decision to deny the claim is upheld, the facility can make a request for reconsideration.
2. Level two is a request for reconsideration, and must be submitted to the Qualified Independent Contractor (QIC) within 180 days from the date the Medicare Redetermination Notice (MRN). The QIC consists of a panel of healthcare professionals that will make the decision as to whether the medical record supports the care and services indicated on the claim.
3. Level three appeals go to the Office of Medicare Hearings and Appeals (OMHA) if the facility believes the medical record supports the claim. This allows the facility to explain to an Administrative Law Judge (ALJ), either via phone, video conference, or in person, why they believe the HIPPS code accurately represents the care and services provided documented in the medical record. The request for an ALJ hearing must be submitted within 60 days from the date the facility received the decision from the QIC.
4. A level four appeal moves to the Medicare Appeals Council, a component of the U.S. Department of Health and Human Service (HHS) Department Appeals Board (DAB), when the facility is confident the medical record supports the claim and disagrees with the ALJ’s decision. The written request must follow the instructions the OMHA has provided. 
5. The level five appeal moves to a request for a U.S. District Court judicial review, and must meet the amount in controversy threshold requirement. At this level of appeal, it may be advisable to seek outside counsel to represent the facility.

Clinical Consulting Support

To reduce the number of denied claims and optimize revenue cycle performance, providers need to ensure documentation in the medical record supports the claim. But every payer has their own unique documentation requirements, making compliance an overwhelming challenge for many long-term healthcare providers. Richter’s clinical consultants understand these complex requirements, and can assist your facility with:

• Medical records audit to ensure the items reported on the MDS that impact billing are supported in the medical record
• Interdisciplinary team (IDT) communication assessment, to ensure information needed to support the patient’s acuity is documented in the medical record during the look-back and as reported on the MDS
• Navigating the appeals process
• Training and education on: 
  o    The Patient-Driven Payment Model
  o    MDS Coordinators and IDT
  o    Nursing documentation
  o    Medicare Part A requirements
• Quality Assurance and Performance Improvement (QAPI)

To learn more about our comprehensive solutions, contact us here or call us at 866.806.0799.

References
1. Additional Documentation Request retrieved November 1, 2023 from Additional Documentation Request | CMS
2. Med Learn Network (mln) Medicare Parts A&B Appeals Process retrieved November 28, 2023 from MLN006562 – Medicare Parts A & B Appeals Process (cms.gov)
3. Original Medicare Appeals retrieved November 28, 2023 from: Original Medicare (Fee-for-service) Appeals | CMS