I see a lot of denials in my job. Some (actually a lot) are legitimate because the agency hasn’t complied with one or more regulations. I have also seen an alarming rate of denials that cause me to question the competence of those performing the reviews.
Last week I received a copy of a denial. It was actually the second denial on the same claim. Palmetto GBA originally denied the claim as they did not think that the Alzheimer’s patient confined to a wheelchair was homebound. My client appealed to Maximus who agreed that the patient was in fact, confined to the home but then denied the claim because there was no documentation of the face to face encounter. The reason my client did not send the documentation is because the episode in question was the second episode and the face to face encounter occurred prior to the first episode.
I am also seeing claims denied because of physician signatures. In some states, my own included, the signature requirement in the minimum standards reads that if the agency documents when the orders were received by the agency, that will suffice as evidence that orders were received timely according to state minimum standards.
The state does not pay your Medicare Claims.
Medicare requires that the physician both sign and DATE his or her signature. Failure to do so will result in a denial.
Statutory denials are like free spins on the slot machine for the folks who review ADR’s and other claims. A statutory denial means that the patient was somehow not eligible for services and therefore, nothing is covered. Compare that to a denial because the reviewer did not think that two of the visits were covered. If the total number of visits was greater than 6, then the two non-covered visits will not result in a loss to the agency. If an ICD-9 code is not supported, the payment will be downcoded usually costing the agency a couple of hundred dollars. But if the patient is not homebound, or there is a problem with the physician, or the orders are not signed, the claim is denied in its entirety and no further effort is required by the person doing the review.
Now, if it were me and y’all can thank your higher power it isn’t, I would go for the statutory denials every time. (And I could find them, too.) These are also the easiest to prevent.
- Everyone in the agency should be aware of the signature requirement. The primary responsibility should lie with the first person who sees the orders whether it is the marketer or the person receiving the mail. However, nobody should see an undated signature without bringing it to the Director’s attention.
- Be obnoxious about dates. Buy some file folder labels and print, ‘Please sign and DATE your signature’ at the bottom of every order. Use red ink. Make it interesting and noticeable. Add a note about dating signatures to your fax cover sheet used for orders.
- Because marketing staff often have more exciting things to discuss, make badges that read: I need a date. That will spark some lively conversations.
- With every ADR that is submitted to your MAC, include the description of homebound status as found in the Medicare Benefits Manual.
- After the patient’s initial episode, ensure that the face to face encounter is included in the summary. That leads me to;
- Write a summary. If your agency is not writing summaries for each episode, begin writing them now. For ADR’s there is nothing wrong about documenting after the fact as long as the documentation is dated on the day that you wrote it.
- If you find an egregious error that cannot be ethically corrected, cancel the claim and send documentation along with your ADR. This won’t affect the outcome but it is the classy thing to do. It also shows that you do know how to recognize errors. Please note that some errors can be corrected ethically. Do not be too hasty in cancelling claims.
- If at all possible, have someone who has not been involved with the patient review the documentation you intend to submit. It is too easy to read between the lines when you know about the patient. The holes are not glaring to you. If you have a branch or if there is an another agency owned by the same organization, trade off ADR’s. If you do not have a sister agency or anyone in your organization, consider using a professional consulting service. I can recommend a good one if you need one.
- Write a cover letter if there are any discrepancies in your documentation. For instance, you may have a very weak patient who progressed to her highest level of functioning with therapy in a prior episode. Note this so the chart does not look as though you have a patient in need of therapy but failed to provide it. (Yes, the reviewer should be able to look at past claims but they should also know homebound status and when the face to face encounter occurs as well.)
- Share your ADR results with your staff. It is so much easier to learn from the errors of others. Too often, agencies don’t want word to get out on the street that they have received a ton of ADR’s. Get over it. ADR’s are being sent out at a rate that might very well save the United States Postal System from financial ruin.
We are always interested in hearing about those strange and somewhat inappropriate denials. Please share with us if you have one that we might teach us all a little something about getting paid. After all, it doesn’t matter how much congress reduces the home health payment if you are never paid.
And as always, we are available to help with ADR’s. We read clinical records as though payment is coming from our own pockets (because it is!) and do our best to get you paid. Mind you, we can only work with what we are given. So, write those summaries and get signatures dated.