Helpful CMS Tools to Simplify Denial Management for Medicare Claims and Maximize Home Infusion Reimbursement
By: Cheri Sciacca, Mediware Reimbursement Services
Billing for home infusion services can be challenging given the changing payer requirements and large volume of denials that providers are seeing these days. When we look deeper, there are numerous reasons why the claims deny. Some denials may even be due to an error on the payer’s side. As providers receive denials, it is always important to step back to analyze the root cause of the denial. This will ensure that you are not only resolving to fix this one instance, but if it is a larger problem, you can also retrain staff so the issue does not reoccur on a future claim.
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CMS also has many helpful resources that providers can turn to that can assist with the appeals process and ensure that you remain within timely filing appeal limits. See below for a list of helpful tips to ensure that you are working denials within a reasonable amount of time and ensure that you have the opportunity to maximize collections.
1. Root causes of denials: Before we start the appeals process, it is important to look at the core reason why the claim was denied in the first place. Some common reasons for denial include: missing CMN or DIF, incorrect modifiers, lack of physician signature, ICD-10 coding errors, or lack of supporting documentation.
2. Identify your deadlines: After you have established what is missing from your claim, or why it was denied, you can begin to start gathering evidence to support you appeal. You will also need to know the final deadline for appeals as every level of Medicare appeals have a specific timely appeal limits. CMS has a helpful appeals timeliness calculator tool that determines the final date to appeal your claim based on the date of the initial determination notice and the level of appeal, (redetermination, reconsideration, ALJ hearing, appeals council review, and judicial review). Depending on the level of the appeal, you may have upwards of 180 days to respond to the denial, but don’t let the extended time fool you! This time does go by fast, especially when you may need to obtain physician signatures, supporting documentation, or medical records which can be time consuming to retrieve.
Therefore, it is crucial to always be aware of your final date to appeal and work backwards so that you are well prepared to plan what is needed for the claim to be approved and what people need to be involved to gather the appropriate information. Even though you have several weeks to respond, the sooner you appeal the claim, the more likely you are to have a positive response and opportunity to collect on the services. When you do submit your appeal, be sure to keep your fax confirmation for your records to show proof of the date and time that the appeal was sent for reconsideration or redetermination. Click here for the link to the calculator.
3. Identify your DME MAC jurisdiction and monitor claim status: Depending on your location in the United States, the District of Columbia, Puerto Rico, the US Virgin Island, Guam, American Samoa, and the Northern Mariana Islands, your DME MAC jurisdiction will govern the appeals process and be the ultimate decision maker on the fate of your claim. It is important to utilize your jurisdiction’s portal to monitor the status of your claim or to see if anything additionally is needed on your part. It is also strongly encouraged to subscribe for the CMS listserv to stay up to date on the latest changes for your state.
- Northeast and northwest region- Noridian Healthcare Solutions covers both jurisdiction A and D. Their website is: https://med.noridianmedicare.com/web/jddme
- Central Midwest region- CGS covers both jurisdiction B and C. Their website is: https://www.cgsmedicare.com
It is vital to your bottom line to work denied claims as soon as possible to increase your chance of having a payable claim. However, the best way to avoid any denials is to create “clean” claims from the start. If you make the investment in the billing process and have all your ducks in a row, you will be much more successful. If your home infusion business is receiving a great deal of denials, you can turn to Mediware Reimbursement Services that has over 20 years of home infusion billing expertise. The Mediware team can assess your current AR and work to address your denial issues with flexible collection projects and consulting services. Learn more today!