Ensuring Systems for Completion of The Medical Review Process

Posted: Nov 27, 2017

For the medical review process to be successful, there must be systems in place. Although many people find the Medical Review process quite tedious, it is a key component of the Long Term Care providers’ everyday processes. Providers who participate in a Medicare Payment Program should expect to have claims reviewed; Additional Documentation Requests (ADRs) and appeals. The reviews could consist of pre-pay, post pay, probes, CERTS, etc. Ensuring systems for completion of ADRs and appeals is the desired result of the Medical Review process.

The essential factors of the Medical Review process are:

  • Communication
  • Teamwork
  • Skilled Documentation (therapy and clinical)
  • Medical Records
  • Scheduling for completion and submission of ADR/appeal
  • Follow-up with client (facility’s corporate liaison and therapy contractor’s MRD) for ADR decisions
  • Filing appeals
  • Follow-up with client (facility’s corporate liaison and therapy contractor’s MRD) for appeal decisions

Whenever a therapy contractor company is providing skilled therapy services in a facility, communication is critical between the facility’s corporate liaison and the therapy contractor’s Medical Review Department. Additionally, the same communication is essential for the therapy team to have with the facility’s clinical team. All entities must be cognizant of working collectively in order to increase the probability of favorable outcomes. If a system is in not in place to ensure completion of the review process, the provider is certain to experience unfavorable outcomes.

Not only is teamwork crucial for successful outcomes, but the Medical Records department is central to the Medical Review process as well. The Medical Records department shoulders much of the financial burden that pertains to the outcomes of the reviews. If the documentation is not filed accurately and cannot be found, it may cost the facility thousands of dollars in recoupment of claims or non-payment of claims. Hence, all therapy and clinical documentation must be completed on time in order to meet Medicare requirements, and it must be filed in the appropriate patients’ medical records. It is critical that all documentation be easily located at all times.

Once an ADR has been submitted to the Medicare Appeals Contractor, communication must continue between the therapy contractor’s Medical Review Department liaison and the corporate liaison. A timeline must be determined in reference to inquiring about a claim’s outcome. Due to appeal deadlines, it is vital to follow-up regarding the ADR outcome or appeal outcome. The claim’s outcome will determine whether or not it is compulsory to file an appeal in order to continue the Medical Review process.

Having systems in place prior to the initial ADR process will ensure successful completion of the Medical Review process and an increase in positive outcomes.

Bethany Nichols, PTA

Director of Medical Review, Century Rehabilitation

Century Rehab offers the following Medical Review & Appeal services:

  • Training on how to complete an appeal
  • Provide all necessary forms and sample letters
  • Auditing of current claims to identify potential deficits in documentation, coding, clinical compliance, and regulatory compliance
  • Managing and processing all aspects of the ADR and medical appeals process

To learn more, please email Bethany Nichols, Director of Medical Review, at bethany.nichols@centuryrehab.com.