Payment denials are not, in every case, caused by uninformed judges, computer glitches or Medicare cost-cutting fanatics. Too often, a payer truly cannot see that the professional clinician described a necessary service or actually performed the service described.
Here is one example. To understand why it is so critical for our industry to generally improve documentation quality, read the following payment denial decision excerpts from an actual case that occurred recently in CMS Region 9, putting yourself in the shoes of the payer. Imagine, as you read, you are buying an expensive item on eBay. The written description of the item and a grainy photograph are all you have to go on before deciding to hand over your credit card number. If those two sources are weak, do you pay or do you ask for more information?
Decision summary
“Payment cannot be made at this time as services rendered to this patient cannot be considered to be medically reasonable and necessary under the guidelines set forth in CMS- PUB 100-2, 7, subsection 30.0, 40.0.
“It has been determined by a review of medical records that the patient was referred for care on June 24, 2009 with a care plan stating that fourteen items would be performed relating to patient assessments, seven goals would be reached, six items would be taught for diabetic process, ten items would be taught for congestive heart failure, twelve items would be taught for deficit of hypertension, physical therapy had two goals, four goals related to blood draws, and an assessment for occupational therapy for home safety skills which is redundant from the previous two disciplines.
“Upon review of the record, not all of this was accomplished. Vital signs were stable, the patient is noted to have a malignant hypertension disease, where elevated blood pressures are part of the norm and difficult to control. No changes in medication were noted, and nursing assessment showed no change in the patient’s condition. Teachings were of a generic and simplistic nature, not meeting the threshold for the definition of skilled care under the Medicare benefit policy manual.
“The homebound status for the patient is noted to be medically restricted from leaving home yet nowhere is there a rationale or written description as to why. The CMS space 485 does not list any medical restrictions nor has been authenticated by the physician signing plan of care. There are no further indicators in this chart as to why the patient would be homebound.
“No considerable taxing effort is exhibited in the clinical notes, no falls have been documented, additionally the patient has been by his own words a participant of outpatient therapy and the patient states he only now has a slight weakness in the left hand and left leg. It is not believable that the patient would not be able to leave home utilizing a taxi, or some type of public transportation, or handicap Van to participate in outpatient therapy.”
Would you address this with prevention or cure?
Regardless of whether or not this individual judge was overreaching the facts in order to support a pre-determined decision to deny, one thing is clear. Every reason cited was completely avoidable.
It may seem that the clinical documentation detail expected by this judge is excessive. Nevertheless, had the clinicians and case managers serving this patient delivered that extra detail, the episode would have been paid and the appeals process would have been unnecessary.
If there is a bottom line for administrators, it is this. You can invest in clinician training or you can invest in pursuing appeal after appeal. The former is less costly but the choice is yours. The only other option available to you is to accept payment denials as they come and absorb the losses.
