Ask the payment expert ... about ABNs and denial letters

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Ask the payment expert ... about the observation stay loophole
Ask the payment expert ... about the observation stay loophole

Can you demystify the ABNs and denial letters process? 

There are several requirements when a resident is discontinuing a Part A or B Medicare stay in your facility. When a resident is admitted and is not being covered by Part A, a Notice of Noncoverage must be issued, giving him or her the reason for not meeting the criteria.

You need to inform a resident discontinuing Medicare A of the expedited review process. A Quality Improvement Organization (QIO) generic notice must be issued at least two days prior to discontinuing service. 

That informs the resident that he or she can immediately appeal that decision, gives the QIO phone number and where to call for the expedited review. The QIO then informs you it received the request and directs you to submit a detailed notice with medical documentation to support your decision. 

Once QIO officials make their binding decision, they will inform you. 

The second notice that you need to consider is the Advanced Beneficiary Notice. This notice is only required when a resident is coming off Medicare Part A services and staying in your facility at a different level of care. It gives the resident the option to appeal that decision directly to Medicare.  

If the resident requests to continue receiving the services and have you bill the service to Medicare, you would complete a demand bill. If your resident has been receiving Part B services and is now being discontinued, he or she must receive the CMS R-131, which is used for all fee-for-service denials.

Most facilities have their therapy department issue these, as most Part B services are related to therapy. It is important that all these forms are completed and all blanks are filled in. An incomplete form can be rendered invalid and your facility can be held liable for the cost of those services.