Medicare denials

  1. I am the Mds coordinator/adon at a nursing facility in Texas, We have been receiving Medicare denials like crazy on part A and part B, we provide the necessary documentation and all is good, but why are we getting them in the first place, it seems like every Medicare resident within a week or so of discharge from the benefits we receive denials. Someone please help me understand why! Could it be billing or something, I'm fairly new to the Mds part and I need to know if it's something I'm doing!
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    About nurseamy25

    Joined: Nov '13; Posts: 11


  3. by   TigerxLiLy
    Im finding most ours are Psych...

    BTW-- did you guys know you can go to your RAC audit website? like for MS RAC audits are done by Connolly-- so you can go to -- and with your medicare number and a valid claim number-- you can get into a webpage that shows you all past,pending, and denied claims?

    I was the first to find out for our whole corporate wide company... due to the RAC audit people did not have a proper address to us.. so all our request were being sent to a random address!! We kept getting recoupment letters.. it is a nightmare right now-- I currently have 6 pending request that was supposedly mailed to us on Sep 30 2013!!! plus a lot of part B request ;(.

    suffice to say-- i got on the website after a representive from Connolly told me about it -- and I am now workinb on those 6 claims which 5 are psych stays...
  4. by   TigerxLiLy
    Im thinking its all about scores, if they are psych related, what the DX codes support.
  5. by   nurseamy25
    Mine is for numerous diagnosis, thanks for the info on Connolly website! Maybe I can find something out, who usually handles these denials?
  6. by   nurseamy25
    And why are we getting them I'm the first place
  7. by   Talino
    There is a multitude of reasons (<--to name a few) why a claim is denied. Find out first from your biller what the primary reason is for each denial and deal with it accordingly.

    If it's diagnosis, your therapist may be entering the incorrect diagnosis codes to bill for the services rendered. It can be an error in data entry, a claim that is already billed by another entity, a glitch from the billing software itself...
  8. by   nurseamy25
    Ok thanks
  9. by   TigerxLiLy
    Each state may have a different RAC audit reviewer too-- so yours may not be Connolly-- but you should be able to out who urs is via your audit request or through the CMS website.
  10. by   nurseamy25
    Ours is Connolly also, I've been reading info all day, the reason for the ADR for one in particular is 7CCPT, I can't find any Medicare codes matching that, I've looked on the cms website and googled everything and I can't figure out what that code means, anyone know?, our billing department (consist of 1person) is saying that all facilites are receiving these ADR's, however, I'm not to sure that's correct. I found a number and called and of course no answer but according the the voicemail they will return my call within 48-72 hours soooo maybe next week I'll know something! Thanks everyone
  11. by   nurseamy25
    Just found out our facility is on a 'pre payment system' and that is why we are getting so many ADR's and RAC's, sooooo that explains why, next question is what causes a facility to be put on a PRE PAYMENT SYSTEM?
  12. by   Talino
    'usually occurs when a provider's billing is above average compared to other facilities in the area for the same service.
  13. by   nurseamy25
    We usually have anywhere from 25-30 residents and usually 5-10 of those are skilled, we always get ultra high rehab rugs on everyone because we are so small and therapy is able to spend more time with individual residents, however, they do the same amount of minutes on every resident, every week, maybe that's a flag? (Just something that crossed my mind)
  14. by   Talino
    Each individual is unique. A therapist eval is crucial. As long as you can prove that the therapy plan of care justifies the need, there is no reason to modify your practices. Document, document, document... they will all be scrutinized. Be aware if anomalies are identified during the prepayment review, they may come back for a postpayment review, that means auditing claims that have already been paid.