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Medicare Compliance & Reimbursement

Medical Review:

Denial Rates For Long-Stay Patients On The Rise

Published on Thu Jun 28, 2012

Ensure that your documentation for patients living longer than the six-month prognosis stands up to scrutiny.With Medicare clamping down on payments for long-stay hospice patients, you need to figure what when your patient no longer qualifies for the terminal diagnosis before an edit hits you and you are faced with a denial.Examples: Home Health & Hospice Medicare Administrative Contractor CGS has revealed the results of two edits of long-stay patients. Under edit topic code 5037T, CGS reviewed claims for hospice patients with lengths of stay greater than 730 days and denied 81 percent of reviewed claims. Under edit topic code 5048T, CGS reviewed claims for hospice patients with LOS greater than 999 days and denied a whopping 97 percent of claims.The stats suggest that medical reviewers are getting tougher on long-stay patient claims. The denial rates are up from 69 and 73 percent from the year-ago time period, respectively, CGS [...]
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