MDS Alert

Published on Thu Oct 26, 2006 PDF

5 ways to win the payment day with the FI.

Think of each additional development request (ADR) as a window of opportunity to provide what the FI needs to pay a claim. If you let that window close without anteing up the requested back-up documentation, your facility will end up with lots of claims denials.

A better alternative: Follow this five-step, systematic plan to help your team respond to each ADR quickly and appropriately.

Read the ADR notice carefully so you can provide all of the information. Consultant Jan Zacny, RN, saw one ADR from an FI that requested all of the MDSs for a resident. But the facility only sent the MDSs for the period billed on the claim. Yet the "FI wanted all MDSs, including those from a preceding stay prior to the current admission to the SNF," says Zacny, with BKD Southern Missouri in Springfield, MO. "When the FI requests all MDSs, it's usually looking at the person's level of care before he went on Medicare Part A."

Cover the RUGs: Even if the notice doesn't asMDSs, you can still fail to provide required documentation if you don't pay attention to the dates of services under review on the ADR. You may see multiple RUG scores relating to those dates, says Joel Van Eaton, BSN, RN, CRNAC, reimbursement clinician for Care Centers Management Group in Johnson City, TN, which manages nursing facilities. And each of those RUG scores will have an MDS with its own assessment reference date, look-back period and supporting documentation, he advises.

1. Know the consequences: "If you don't submit all of the required documentation, you could end up with a total denial [of the claim] or the FI could adjust the RUG score down," says Van Eaton.

Tip: Send the signed and dated physician certs/recerts along with all of the information submitted to support the billed services, advises Jan Blake, RN, a consultant with The Broussard Group in Lake Charles, LA. "The required supporting documentation varies with each FI, so it is better to be safe than sorry," she says.

2. Know that a day late will mean lots of dollars short. You typically have 30 days to respond to an ADR, although one or two of the FIs have allowed 45 days, says Marilyn Mines, RN, BC, RAC-C, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL. The ADR notice will indicate the time-line, she adds. If you miss the deadline, "the FI will deny the claim, and the facility will have to appeal it," cautions Claudia Reingruber, CPA, principal of Reingruber & Company in St. Petersburg, FL.

Tip: Check the electronic system daily to see if you have a request for an ADR, advises Mines. "The clock starts ticking the day the notice is posted," she cautions.

3. Use a team approach to complete and double-check the ADR package before sending it. Develop an action plan and policy to ensure that all of the players involved in responding to an ADR know their responsibilities, suggests Mines. For example, you need a method to notify everyone of the ADR and the timelines each discipline must follow in reviewing the resident's record, she says. Then someone should monitor the process to make sure the facility doesn't miss the due date, Mines adds.

Have the entire Medicare team review the ADR packet, suggests Reingruber. That includes the MDS coordinator, the nurse who knows the resident's care, the director of rehab and medical records -- if that's the department that maintains physician certifications, she says.

Finally, have an outside "eye" review the documentation responding to the ADR before submitting it to the FI. That person can make sure that the packet contains all the requested documents and "those that will support the Medicare coverage, as well as the RUG categories billed," says Mines.

4. Lay a persuasive paper trail.  Arrange the record and label or highlight the requested information, suggests Mines. The goal is to "make it easier for the reviewer," she says. In Mines' experience, facilities that send "organized packets" tend to have positive outcomes.

5. Keep a copy of what you sent the FI. That's important to do because if the FI denies the claim, "it tosses all of the information" you've already sent, says Mines. Or the FI could say it hasn't received the information or ask for more documentation, she adds.