Poor documentation crippling providers with Medicare denials, expert notes

Marilyn Mines
Marilyn Mines

Untimely certifications, missed or incorrectly billed Change of Therapy documentation, or a lack of documentation supporting a signed physician order for skilled therapy are among the top reasons Medicare claims denials are hitting facilities, an expert said Wednesday.

In one review of Prepayment RH (high rehabilitation) categories in six months from 2016, Noridian Healthcare Solutions found that out of 75 claims, nearly half were either partially or totally denied, said Marcum Senior Manager of Advisory Services Marilyn Mines, RN, BC, RAC-CT.

She shared an example of how such a denial occurs with attendees at the LeadingAge Illinois annual meeting, which is taking place this week at Navy Pier in Chicago.

“A facility wanted me to help appeal a denial, and I said, ‘Send me the documentation,'” she said, noting that she always wants a facility to be paid for its work. Sadly, “For two weeks that they were denied, the therapy notes said exactly the same thing in the progress notes. No progress had been made; there was no change in a plan of treatment. I said, ‘How can you appeal something where your staff documented no progress?'”

With Change of Therapy documentation, “If we have a Medicare meeting, and have the MDS and therapy people talk, we can avoid some of these problems.”

Other reasons for claims denial include late or lacking Advance Beneficiary Notice or the incorrect RUG level billed.

It has to be clear why a resident needs physical therapy or occupational therapy, Mines said.

The MDS should not contradict therapy, but it also doesn't mean that a resident can't be moving and still need therapy.

“The resident is walking around: How have we justified therapy?” she posed to attendees. “Don't just say walking around the unit. You say he refuses to use a walker, he is unsteady, the CNA has to stand by him, and this all justifies why we have therapy. He may have ambulation but needs therapy.”

Other speakers at LeadingAge Illinois included Susan Hildebrandt, vice president of workforce initiatives at national LeadingAge.

Providers cannot afford to not calculate turnover, she warned. It is looking at the number of individuals at your campus and divide by termination, and to break down between voluntary, such as retirement, versus involuntary.

Some factors impinging the ability to attract long-term care employees includes that the U.S. labor pool is at the lower level in 38 years, an aging population, ageism and increasing desire for flexible work. The latter principle is especially true among millennials, she noted.

Long-term care ultimately needs better brand awareness for attracting new workers to the field, she said.

“People don't know what it means to work in aging services,” Hildebrandt explained. Plus, there's a need to provide good management and opportunity to grow.

“All of the wonderful people at our communities may lack empowerment or be engaged in our organization,” she said. “People do not tend to leave their organization, but they do leave their boss.”

LeadingAge plans to launch a workforce initiatives center, she added. The LeadingAge Illinois meeting concludes Friday.