While the goal of submitting claims in the Review Choice Demonstration (RCD) project is to obtain provisional affirmation or payment, not all claims may end up achieving this status. At that time the home health agency is faced with a choice of what to do with the claim: write it off as non-billable or appeal and seek payment.
Even with the unlimited ability for resubmission under Pre-Claim Review (Choice 1), some claims will not achieve a provisional affirmation status. If the home health agency feels strongly for coverage, submitting the claim for final billing will generate an automatic denial. And for the Additional Development Request (ADR) prepayment (Choices 2, 5) and postpayment (Choice 4) options, an unfavorable decision only gives one option to obtain payment: appeal the denial.
This presentation provides an overview of the RCD choices, agency options for a non-affirmed or denied claim, and preventive measures that minimize chances of an unfavorable RCD claim submission. This uses common denial reasons (applicable to the ADR choices) and non-affirmation reasons (for pre-claim reviews) and addresses how to prevent these for a smoother RCD experience. The process for filing appeals is also covered.
Some areas covered include physician face-to-face (F2F) issues, certification deficiencies, and the most common medical necessity denials, including therapy documentation. A thorough walk-through of F2F encounter requirements and how the F2F content links with PDGM payment and possible denials or non-affirmations is covered. How these are applied to appeals for denied claims is presented.
Speakers/Course Authors - Joe Osentoski
Attendees of this workshop will:
- Attendees with have clear understanding of the RCD choices: state RCD choices.
- Attendees can state key clinical items to submit during RCD reviews.
- Attendees with have understanding of the options for non-affirmed or denied claims submitted under RCD. State available options for each.
- Attendee will obtain knowledge of common denial non-affirmation reasons along with preventive actions to minimize their occurrence. State and apply these to agency processes during review and possible appeals.
- Answer attendee questions
By completing/passing this course, you will attain the certificate HCAF Course Certificate
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