Ask the payment expert: payment trends related to medical review

Share this content:
Ask the payment expert
Ask the payment expert

What payment trends have you seen related to medical review?

Probably the biggest trend is denials

 based on medical necessity of care. Many claims are being cut in the last few weeks of the stay based on the finding that the care should have transitioned to restorative care. This finding may be based on therapy documentation not supporting the stay. It also may be based on the belief that therapy is trying to progress the resident beyond what the intermediary feels is needed.

It has always been the goal of most therapists to get residents back to independence if that was their prior level of function. Now the intermediary often wants the care transitioned to restorative care when the resident needs minimal assistance.

Another basis for denial is lack of consistency in documentation. All of it should support the reason for the skilled coverage. Often, we see that nursing, social services, and/or dietary do not even know the reason therapy is treating the resident. Consequently, they will document how well the resident is doing rather than documenting the functional limitations the resident has that support coverage.  

One of the biggest lessons we have learned through medical review is that while the rules have not changed, the interpretation of them has.

The reviewer now has the MDS data when medical review is completed. Denials are almost automatic if the MDS does not match the service being provided. An example is a denial of speech therapy due to the MDS being coded as no communication problems.  The solution? Make sure your staff is trained in Medicare documentation.

If you get an Additional Development Request (ADR) from your Fiscal Intermediary/Medicare Administrative Contractor, get assistance. Your proper reimbursement depends on it.