‘Tis the season for a lot of things merry, but appeal and denials are not so cheery. Requests from Medicare Administrative Contractors (MAC) in the Skilled Nursing Facility (SNF) and Medicare Part B outpatient clinics are on the rise. Time is of the essence when a facility receives communication from a MAC; however, some requests are more impactful than others. Let’s review the various types of appeals and the focus areas. The Centers for Medicare and Medicaid (CMS) MLN Booklet on the Medicare Part A and B Appeals Process is a great reference.
The first phase in a request for documents is called the Redetermination which will come from your MAC. Facilities must know their MAC and have continual access to their website. Review of the Local Coverage Documents (LCD) is important to understand the documentation and coding expectations of the specific MAC who reviews your claims. After the facility receives the initial determination, the facility will have 120 days to file the appeal for a Redetermination.
If your Redetermination appeal is deemed to be unfavorable, the next level is called Reconsideration. The Reconsideration phase is completed by the “QIC” which stands for “Qualified Independent Contractor.” The QIC is C2C Innovative Solutions, Inc. for Part A East and Part B North and South claims; Maximus, Inc. is the QIC for Part A West. After the Medicare Redetermination Notice (MRN) is received, the facility has 180 days to file the Reconsideration appeal information to the QIC. The reconsideration is the last opportunity to submit additional data to support the claim.
The next level of appeal is to the Office of Medicare Hearings and Appeals (OMHA) Disposition. Once the QIC decides, the facility has up to 60 days to submit a request. The amount in controversy (AIC) must be at least $180.00 for 2022 and 2023.
The final level of appeal is the US District Court Judicial Review, known as the “ALJ”. The 2023 AIC threshold is $1,850.00. Typically, there will be a phone hearing and your representative will be able to discuss the case with the judge.
TPE
The Targeted Probe and Education (known as TPE) is a common first contact from the MAC. CMS on TPE is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. The premise being, once records are submitted, and reviewed by the MAC, the MAC provides education to the facility’s or clinic’s team to rectify any documentation or coding errors. After the education, a sample of records is reviewed again; however, any problems that fail to improve after three rounds of education sessions will be referred to CMS for next steps. Possible scenarios may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or another action.
CMS is currently performing a TPE round of audits on Medicare Part A Patient Driven Payment Model (PDPM) records for SNF’s. On May 15, 2023, Transmittal 12032 was released from CMS announcing a SNF 5-Claim Probe and Educate Review. The purpose of the review was to lower the SNF improper payment rate due to the primary root cause of SNF errors due to missing documentation. If you are a SNF and have not received word of these TPE audits, they WILL be coming. LW Consulting, Inc. has seen an increase in the number of requests this past quarter. All facilities must be reviewed within a year of the announcement. It is important to note, these are prepayment audits (with only one round of review instead of the typical TPE three rounds). Consider a calculation of the average claim payment multiplied by five records for the CMS TPE audit to calculate the facility prepayment loss of revenue. If a facility fails to pass the audit, CMS will provide more scrutiny.
What Else is CMS Reviewing?
CMS is also focusing on the coding and documentation of the diagnosis of schizophrenia. This CMS initiative for SNF’s only began on January 18, 2023. If your facility is concerned about inaccurate coding of the schizophrenia diagnosis, in Section I6000 on the Minimum Data Set (MDS), consider closely reviewing this information.
Final Thought and Focus Areas
Other big focus areas LWCI auditors are currently reviewing are issues with denials regarding insufficient documentation to support the need for a skilled qualified therapist to complete the task. CMS MACs are looking closely at medical necessity and the repetitive nature of documentation to determine if the skills of a therapist are supported. These requests come from the Supplemental Medical Review Contractor (SMRC). Noridian Healthcare Solutions, the current SMRC, will send requests to providers and suppliers for additional documentation on claims selected for medical review. Unified Program Integrity Contractors (UPICs) are by far the most serious financial threat to your practice. The stated purpose for the UPICs is to investigate instances of suspected fraud, waste, and abuse in Medicare or Medicaid claims. If you get notice of a UPIC, which may come in the form of a visit, you may want to meet with an attorney or a consultant.
‘Tis the season to ensure your facility is on track in the New Year.
If your facility or clinic is receiving MAC communication regarding denials or requests for documents and you have questions or need assistance, we are here to help. LWCI auditors often review documents for missing technical requirements, medical necessity, or help with appeal writing. Call Kay Hashagen, PT, MBA, RAC-CT at (410) 777-5999 or [email protected].
