Ask the payment expert: How to maintain solvency under increased Medicare scrutiny (Part III)
A: In the last year, providers have seen more denials due to records not supporting the medical necessity of care at the intensity and duration of services that were provided. For example, reviewers are frequently saying that the final one to two weeks of therapy could have been transitioned to restorative care.
Auditing your Medicare charts is a way to prevent denials and maintain your most profitable reimbursement.
Complete a Medicare audit on at least an annual basis. Many large corporations already have a reimbursement auditing process in place with staff ready to complete these reviews. If you do not, have a reputable firm complete a Medicare audit for you. You need to have a minimum of a nurse to review clinical issues (MDS coding, nursing documentation, timeliness of assessments) and a therapist to review therapy documentation and necessity of care.
Another component is a review of the UB-04 and billing requirements. This can be done by anyone who is knowledgeable in billing procedures. Although it may cost you to have this type of review done, it is money well spent. It will help you reduce your risk for denials either from Medical Review or RAC reviews. It also can be considered a part of your Corporate Compliance program and subject to Quality Assurance procedures and/or through your corporate attorney so that the results are protected by attorney/client privilege.