Top Ten Tips for a Successful ALJ Hearing

Please note: Handouts and Recordings will be emailed
following the webinar. Please allow for processing time.
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. (HHI)
Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 1
Top Ten Tips for a Successful ALJ Hearing
Hello everyone!
To have the Audio experience, please
Dial the number: 1 (626) 521-0032
Access code: 838-687-657
Audio pin will be shown after joining the training
If you have any difficulties connecting, please call Mary at
1-978-887-8919 x 13

Top Ten Tips for a Successful
ALJ Hearing
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc.
(HHI)
Presented by:
Caroline Mullin, OTR/L, RAC-CT
Claims Review Specialist

Harmony Healthcare International, Inc.
About Caroline
Claims Review Specialist for Harmony Healthcare
International, Inc. and Corporate Consultant for HHI since
2008
MS OTR/L, RAC-CT
Education:
Masters of Science in Occupational Therapy from
Spalding University in Louisville, KY
Continuing Education in Contracture and Geriatric
Therapeutic Exercise Courses
Experience:
Senior Occupational Therapist and Director of
Rehabilitation Services at Episcopal Senior Life
Communities in Rochester, NY
Expert in Denials, Appeal letters, and prepping
facilities for ALJ hearings
Copyright 2014 All Rights Reserved 3

Objectives
The Learner will be able to summarize goals
of Medicare Medical Review
The Learner will be able to identify and
articulate examples of the Medicare Medical
Review Process
The Learner will be able to identify strategies
for preparation and execution of an ALJ
hearing
Harmony Healthcare International, Inc. 4Copyright 2014 All Rights Reserved

Auditing Agencies and
Contractors

OIG Audits
How We Got Here

Wall Street Journal, November 12, 2012
Thomas Burton, November 2012
“More intensive services were done than
actually performed”
“Patients could not benefit from it”
“Cutting fraud” Obama

Wall Street Journal
Sample 499 claims by 245 (stays)
nursing facilities
1 home reached a settlement agreement
on allegations of fraudulent billing for
“medically unnecessary” therapy
“More therapy during the period on which
bills were based”
“Look-Back Period”

OIG Report:
Claims in 2009
25% billed all claims in error 1.5 billion
26% claims not supported in the
medical record
542 million in over payment
“Majority” error “upcoded”*
Many Ultra High
* Original RUG was a higher paying RUG than the revised RUG

OIG Report:
Claims in 2009
20.30%
2.50%
2.10%
75.10%
Billing Errors
Issues found with skilled-nursing
facilities’ Medicare claims, based on
an outside review of 2009 data
Properly billed
Billed for a more
expensive treatment
than was provided
Billed for a less
expensive treatment
than was provided
Billed for a condition
not covered by
Medicare
Source: Department of Health and Human Services
Office of Inspector General

Increase and expand reviews of SNF
claims
CMS should instruct its contractors to conduct
more medical reviews of SNF claims
Use its Fraud Prevention System to
Identify SNFs that are Billing for Higher
Paying RUGs
CMS should use its Fraud Prevention System
to identify and target these SNFs
OIG Recommendations

Monitor Compliance with the New
Therapy Assessments
As of October 2011, SNFs must complete a
“change of therapy” assessment when
the amount of therapy provided no longer
reflects the RUG and an “end of therapy”
assessment when therapy is discontinued
for 3 days
OIG Recommendations

OIG Recommendations
CMS should instruct its MACs and
RACs to closely monitor SNFs
utilization of these assessments through
analyses of claims data. Such analyses
will identify SNFs that are using the
assessments infrequently or not at all.

Change the Current Method for
Determining How Much Therapy is
Needed to Ensure Appropriate
Payments
CMS should instruct the MACs to
provide education to all SNFs, as well
as specific training to selected SNFs, to
improve the accuracy of their MDS
reporting
OIG Recommendations

Follow up on the SNFs That Billed in Error
In a separate memorandum, we will refer to
CMS for appropriate action for the SNFs with
claims in our sample that had inaccurate RUGs
or that did not meet coverage requirements
OIG Recommendations

Recovery Audit Contractors
17

The Recovery Auditors Program Mission
The Recovery Auditor detect and correct past
improper payments so that CMS can
implement actions that will prevent future
improper payments:
Providers can avoid submitting claims that do
not comply with Medicare rules
CMS can lower its error rate
Taxpayers and future Medicare beneficiaries
are protected
18

If you bill fee-for-service programs,
your claims will be subject to review
by the Recovery Auditors
Target areas are posted on the
RACs’ websites
19

The Recovery Audit Review Process:
Recovery Auditors review claims on a post-payment basis
Recovery Auditors use the same Medicare policies as
Carriers, FIs and MACs: NCDs, LCDs and the CMS Manuals
Three types of review:
Automated (no medical record needed)
Semi-Automated (claims review using data and potential
human review of a medical record or other documentation)
Complex (medical record required)
Recovery Audits look back three years from the date the
claim was paid
Recovery Auditors are required to employ a staff consisting
of nurses, therapists, certified coders and a physician CMD
20

The appeal process for Recovery Audit denials
is the same as the appeal process for
Carrier/FI/MAC denials
“Discussion Period” by phone in the first 15
days of denial
If you disagree with the Recovery Auditor’s
determination:
File within 30 days to avoid recoupment
Up to 120 days to appeal
Interest will still accrue during the appeal process
21

ZPIC Audit

Frequency of Medical Review
Significant increase in frequency of
Medical Review
Office of Inspector General (OIG) Reports
Department of Justice (DOJ) Review
Zone Program Integrity Contractor (ZPIC)
Recovery Audit Contractor (RAC)
Budget cuts
Expect to be Reviewed

Insulate, Insulate, Insulate!!!
Zone Program Integrity Contractor
(ZPIC)
CMS launched another major initiative to target
providers other than the hospital setting as the
RAC auditors have been focusing on hospital
audits
Southeast, South Central, Midwest, Northeast
and West Coast regions of the U.S. are
seeing the most ZPIC audits at this time

Zone Program Integrity Contractor
(ZPIC)
ZPICs
SafeGuard Services
AdvanceMed
Health Integrity
Integriguard
Surprise on-site visits
Targeted data analysis
Random audits
100% pre-payment holds

On-site Medical Record
Review Audits
AdvanceMed
Request for 160-170 Medical Records
14 Days to Submit
Requesting ONLY Therapy
Documentation
Therapy Staffing levels were requested
AdvanceMed interviews with Staff

ZPIC Audits
ZPIC targets are often selected based on
Unusual trends or changes in utilization over
time
Specific schemes noted by CMS that
inappropriately maximize generated
reimbursement
Referrals from law enforcement and other
sources for possible fraud and abuse
High volume or high cost services that appear
like they are being over utilized

ZPIC Audit Targets
Providers with patients having unusually long lengths
of service or high-case mix levels
HHAs with patients having extended numbers of
visits
Hospice providers with high, length-of-stay patients
A SNF with a large volume of high “RUG” level claims
Disgruntled employee who threatened you as a
“whistleblower”
Operators in areas identified as high risk for fraud
(Miami-Dade and Broward Counties)

ZPIC Audits
ZPICs are specifically allowed to
Place you on pre-payment review
The pre-payment review flag remains until a
determination is issued on the audit, which
can take a long time
Place you on billing suspension
Withhold payments

ZPIC Audits; What auditors demand at
an unscheduled visit
Require proof that you are operating at the
identified practice locations
Interview your staff
Required documentation that you meet
conditions of participation
Submit a request for records, including:
Business records
Medical records
Members of law enforcement can accompany
ZPIC auditors

ZPIC Audits; How to Prepare?
Create or review your Compliance Plan
Have an outside party conduct an annual coding
accuracy review
Perform data analysis to determine areas of
exposure
Review documentation procedures
Train staff on how to respond to questions from
ZPIC auditors

Review Audits
Rehab and MDS Questions
Sample therapy staff interview
questions:
1. Do you feel pressure to meet your RUG
levels?
2. Who has the say on discharge from
therapy?

Review Audits
Sample MDS staff interview questions:
1. Who decides the ARD?
2. Do they provide group and concurrent
treatments?

Harmony Healthcare International
Top 10 Tips for a Successful
ALJ Hearing

Tip #1: Know your Medicare
guidelines

Medicare Medical Review
Claim Determinations
36

Technical Denial Reasons
Response to Additional Documentation Request
(ADR) did contain documentation requested
Documentation not received within requested
time frame
Physician Certification not signed or missing
Therapy Billing logs do not support billing
Part A – MDS Assessment
Part B - 8 Minute Rule
Illegible documentation
Hospital documentation was not submitted

Clinical Denial Reasons
Documentation did not support medical
necessity
Documentation does not support daily
skilled intervention by a qualified
therapist
Documentation in the medical records
must support continued progress

Denial Reasons
Services provided were likely clinically
appropriate but the documentation
provided to reviewers did not support:
Technical requirements
Medical necessity
The skills of a therapist were required
Functional outcome
Need to receive an inpatient level of care

Denial Reasons
Reasonable and Necessary
The amount, frequency and duration of
services were not reasonable, given
the patient’s current status
ST documentation demonstrates that
the therapist worked long enough with
the beneficiary to develop a
restorative program

Denial Reasons
Skills of a Therapist
ST minutes were reduced based on clinical
judgment because documentation did not
support the billed minutes were reasonable
and necessary. The beneficiary could not
participate in self feeding during this period and
required the speech therapist to assist with 100%
of the feeding.
Documentation did not support medical necessity
and need for continued skilled therapy. Patient
needs assistance and supervision.

Denial Reasons
Deconditioning
Skills of a therapist are not required to maintain
function or improve strength and endurance
Services related to activities for the general
good and welfare of patients (e.g., general
exercises to promote overall fitness and
flexibility, and activities to provide diversion or
general motivation), do not constitute physical
therapy services for Medicare purposes
Practicing of previously taught exercises does
not require the skills of a therapist

Denial Reasons
Restorative Level of Care
Skilled therapy was provided when
non-skilled maintenance services
would have been more appropriate
Restorative level of care provided
Documentation supports that
restorative nursing could have helped
the beneficiary progress versus skilled
rehabilitation services
Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved 43

Denial Reasons
Custodial Level of Care
Skilled rehabilitation and nursing services
were custodial in nature and could have
been met with restorative nursing, family
member, or nursing provision of
intermittent skilled rehabilitation and
nursing services and that needs were
custodial in nature and could have been
met with restorative nursing, family
member, or nursing assistant

Denial Reasons
Prior Level of Function
The therapist ignored the patient’s prior level of
function and set unrealistic goals
Prior level of function was illegible. Prior level of
function was blank.
Patient's functional level had not changed when
compared to his prior level of functioning
documented in the medical record
Weekly nursing progress notes demonstrate that
the beneficiary required the same amount of
assistance (extensive assistance) prior to and after
the hospital stay

Denial Reasons
Rehab Potential
The medical record did not support that
the condition of the patient would
improve materially in a reasonable and
generally predictable period of time
Poor Rehab potential

Denial Reasons
Goals
Goals are not functional (i.e., patient
will perform 10 repetitions of upper
extremity exercises with the yellow
theraband)
Duplication of services between
disciplines

Denial Reasons
Lack of Functional Progress
Gains were not significant and there was no
indication of carryover of the functional task
Lack of documentation relating to the patient
having the potential to show significant
progress
No significant improvement with functional
ability
The outcome of therapy treatment was not
documented
Failure to document a complete treatment plan
as outlined in Documentation Required section

Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc.
Skilled Interventions
Medicare will support continued
services when the patient is not making
progress if there is documentation that
multiple skilled interventions have been
trialed
It is appropriate to give each trial an
adequate amount of time to determine if
the patient will progress
49

Denial Reasons
Modalities
Electrical Stimulation used to treat motor function
disorders, such as multiple sclerosis, is considered
investigational and therefore, non-covered
Electrical Stimulation used in the treatment of facial
nerve paralysis, commonly known as Bell’s Palsy, is
considered investigational and therefore, non-covered
Diathermy and Ultrasound heat treatments for the
treatment of asthma, bronchitis, or any other
pulmonary condition are considered not reasonable
and necessary, and therefore, non-covered

Denial Reasons
Cognitive Therapy
The record documented a diagnosis of
Alzheimer’s disease. SLP documentation
does not support further significant
practical improvement could be expected.
Medical justification for ST services is not
established
Speech treatment cognition for dementia
Poor progress with cognition

Denial Reasons
Inpatient Level of Care
Documentation did not support the
need for inpatient level of care
No daily skilled care requiring a
stay in the SNF
Supervised level of care

Denial Reasons
Medical Record Conflicts
Nursing notes mostly dependent
ADLs/functional tasks throughout the SNF
stay. Nursing note indicated there was no
improvement and fluctuation of progress
with self-care tasks.
MDS assessments indicate that the
beneficiary's ability to perform functional
tasks/ADLs did not improve from the 5-day to
the 90-day assessment

Documentation to Support
Identified Risk Areas
Identify potential denial risk areas
What might the reviewer have not seen in the
documentation provided to lead the reviewer to deny
services?
What additional documentation may be included to
further support skilled rehabilitation and nursing
services provided?
Consultations/ED Visits
Care Plan
Physician Progress Notes
Social Services/Dietary Notes

What is Skilled Care?
Anchoring the Skill

Copyright 2014 All Rights Reserved
Medicare Requirements
The patient requires Skilled Nursing
Services or Skilled Rehabilitation
Services (i.e., services that must be
performed by or under the supervision
of professional or technical personnel)
(See §214.1 – 214.3)
Harmony Healthcare International, Inc. 56

Medicare Eligibility
Treated for a condition which was
treated during a qualified stay…or…
which arose while in a SNF for a
treatment of condition for which the
beneficiary previously was treated in a
hospital
For Example:
Fractured hip develops pneumonia
secondary to immobility

Medicare Requirements
The patient requires these skilled
services on a daily basis (see
§214.5)
Daily Nursing Notes
Treatment Sheets

59
Skilled Rehabilitation
Transmittal 262
On a daily basis
Services rendered are reasonable and
necessary
MD ordered
Practical matter
An appropriately licensed or certified
individual must provide or directly supervise
the therapeutic service and coordinate the
intervention with nursing services
Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved

Medicare Benefit Policy Manual
Chapter 8 Revisions
December 2013

Why Update the Policy Manual?
CMS Settlement
CMS revised the Medicare Benefit Policy
Manual (December 2013) and will revise
other Medicare Manuals to correct
suggestions that Medicare coverage is
dependent on a beneficiary "improving"
New policy provisions state that skilled
nursing and therapy services necessary to
maintain a person's condition can be
covered by Medicare

Medicare Benefit Policy Manual Update
“Coverage for such skilled therapy services does not
turn on the presence or absence of a
beneficiary’s potential for improvement from
therapy services, but rather on the beneficiary’s need
for skilled care. Therapy services are considered
skilled when they are so inherently complex that they
can be safely and effectively performed only by, or
under the supervision of, a qualified therapist. (See
42CFR §409.32) These skilled services may be
necessary to improve the patient’s current condition,
to maintain the patient’s current condition, or to
prevent or slow further deterioration of the
patient’s condition.” - December 2013

(continued)
Therapy services are considered skilled when
they are so inherently complex that they can be
safely and effectively performed only by, or
under the supervision of, a qualified therapist.
(See 42CFR §409.32) These skilled services
may be necessary to improve the patient’s
current condition, to maintain the patient’s
current condition, or to prevent or slow
further deterioration of the patient’s condition”
- December 2013

“The services must be provided with the expectation,
based on the assessment made by the physician of the
patient’s restoration potential, that
The condition of the patient will improve materially in
a reasonable and generally predictable period of
time; or,
The services must be necessary for the
establishment of a safe and effective maintenance
program; or,
The services must require the skills of a qualified
therapist for the performance of a safe and effective
maintenance program”
– December 2013Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 64

RAI User’s Manual Update
RAI User’s Manual September 2013:
Therapy services can include the actual
performance of a maintenance program in those
instances where the skills of a qualified therapist
are needed to accomplish this safely and
effectively
However, when the performance of a maintenance program
does not require the skills of a therapist because it could be
accomplished safely and effectively by the patient or with the
assistance of non-therapists (including unskilled caregivers),
such services are not considered therapy services in this
context

Tip #2: Ensure your medical
record has supportive
documentation

What is Skilled Care ?
Direct Skilled Nursing Services
Management and Evaluation of a Care
Plan
Observation and Assessment
Teaching and Training
Skilled Rehabilitation

Skills of a Therapist or a Nurse
Services must require the expertise, knowledge,
clinical judgment, decision making and abilities of a
therapist or a nurse that qualified personnel, trained
caretakers or the patient cannot provide
independently

Skills of a Therapist or a Nurse
Documentation must support:
Description of skilled treatment
Changes made to the plan of care
due to assessment of the patient’s
needs
Medical complexity
Why the clinical and critical thinking of
a therapist or a nurse are required

Tip #3: The best defense is a
good offense

How Does Your Team Measure Up?
Take the Harmony Healthcare International
(HHI) Denied Claims Appeals Process
Proficiency Exam
http://info.harmony-healthcare.com/medicare-
denied-claims-guide

1. To what degree does your facility have
a monthly Triple Check system in
place?
a. The team meets every month to review UB-04s,
MDS assessments, and Therapy Billing Logs
b. The team tries to meet each month, but
sometimes it’s hard to get the team together
c. The Billing Department double checks
everything
d. There is no a Triple Check system in place

2. ICD-9 codes on the UB-04 are determined
using which of the following methods?
a. The ICD-9 coding is updated monthly as the patient’s
skilled nursing and therapy needs change
b. The ICD-9 coding is determined shortly after the
patient is admitted based on nursing and therapy
needs
c. The ICD-9 coding is discussed by the team prior to
end of month billing to ensure codes reflect the reason
for hospitalization and skilled nursing needs
d. ICD-9 codes on the UB-04 are not a priority and likely
do not reflect the patient’s skilled needs

3. Which item best represents how therapy
evaluations support a decline in function?
a. Therapy evaluations document a clear prior level of
function and a significant decline from the patient’s highest
practicable level of function
b. Therapy evaluations document a clear prior level of
function, but not all functional areas are tested on
evaluation
c. Therapists are not always able to obtain a prior level of
function or not all functional areas are tested on evaluation
d. Evaluations lack the details required to support a decline in
function

4. Accuracy on the Physician Certification Forms to
reflect the skilled care provided by the Nursing and
Therapy departments is achieved through which
process below?
a. Skilled qualifiers notated on the Certification forms are
discussed as an interdisciplinary team and reflect the details
of both nursing and therapy skilled services
b. Skilled qualifiers are pulled from the hospital discharge
summary; therapy disciplines are also listed if the patient is
evaluated per physician orders
c. Physician ordered therapies are listed on the form; the skilled
nursing needs are only included if therapy is not involved
d. Physician Certification Forms are not in use

ADR/Help Letter Checklist
HELP LETTER REVIEW CHECK LIST
Period Skilled Nursing Chart Review: From: __________________ To: _________________
Medicare Admission Date: ___________ Diagnosis: ________________________________
MDS Reference Dates Review
5 day 14 day 30 day 60 day 90 day
SOT/EOT
OMRA
ARD
Billing Dates
RUG/HIPPS
COT COT COT COT COT COT
ARD
Billing Dates
RUG/HIPPS
ICD-9 Codes
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Tip #4: You have to play to
win!

Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc. 78Harmony Healthcare International, Inc. 78
What To Do When You Get An ADR

Help Letters and Appeals
In order to effectively manage a Medicare
Help Letter or denied claim, the facility must
work as a team to gather pertinent
information
Assign a team leader to oversee the
preparation of the ADR/appeal package
All members of the team should review the
medical record to ensure completeness

The following team members are beneficial in this
process:
MDS Coordinator
Director of Nursing
Unit Managers (consider)
Restorative Nursing program Manager
Director of Therapy
Any therapy professionals involved in the patient’s care
Social Services
Dietary
Additional team members who participated in care

Many times the process starts with an
Additional Development Request (ADR)
These can be triggered by items
specific to the patient, such as:
RUG score
ICD-9 code billed
Wide spread probe

It is important to read the ADR or denial
letter thoroughly as the letters will assist
the facility in gathering the appropriate
information
Review the list of items provided in the
decision statement to include in the
medical record
Consider additional info not listed that will
support the services provided

Appealing Medicare
Denied Claims

Appeal Process
Common practice to receive
communications from Medicare review
agencies requesting proof of skilled
services
Understand the process to manage the
inquiry in a timely and detailed manner
in order to minimize lost Revenue

CMS Overview
Section 521 of the Medicare, Medicaid, and
SCHIP Benefits Improvement and Protection
Act of 2000 (BIPA) included provision aimed
at improving the Medicare fee-for-service
appeals process
Part of the provisions mandate that all
second-level appeals (for both Part A and
Part B), also known as reconsiderations, be
conducted by Qualified Independent
Contractors (QICs)

CMS Overview
Centers for Medicare & Medicaid
Services (CMS) contracts with Medicare
Administrative Contractors (MACs) to
assist with local claims processing and
the first level appeals adjudication
function

Probe Reviews
Under probe reviews, contractors may
examine 20-40 claims per provider for
provider-specific problems
Contractors also conduct widespread
probe reviews (involving approx. 100
claims) when a larger problem, such as
a spike in billing for a specific
procedure, is identified

Appeal Process
It is not uncommon for an ADR to
result in the denial of part or all of
a claim
Once an initial claim determination
is made providers have the right to
appeal

Monitor the Appeal
Internal tracking system to monitor
When ADR or denial was received
When package was sent out
Final results of the review

Tip #5: Do it right the first time

Appeal Rights
Medicare offers five levels in the Part A and Part B
Appeals Process:
1. Redetermination by a MAC
2. Reconsideration by a QIC
3. Hearing by an Administrative Law Judge (ALJ)
4. Review by the Medicare Appeals Council,
within the Department Appeals Board
5. Judicial review in U.S. District Court

Appeal Rights
Right to Appeal
All appeal requests must be
made in writing

The Appeal Package
List of items typically requested:
Initial MDS and any MDS that corresponds to
the billed dates of service and look back
All physician documentation for dates of service
in question
Physician’s orders
MD certifications
MD progress notes
History and Physical

The Appeal Package
Items to include
Include all information in the medical
record from the look back period
MD re-certifications for skilled stay for
billed dates:
If certification is signed by a NP, be aware that
there may be a request for the facility to submit
an attestation letter verifying no direct or
indirect employment relationship with the SNF

The Appeal Package
Items to include
Pre admission data
Hospital Records that validate a qualifying stay
Daily Nurses notes
MDSC notes
Case Manager notes
Care Plan
MAR and TAR

The Appeal Package
Items to include
Documentation of all therapies provided
Evidence of MD supervision
Evaluations
Progress notes and
Therapy billing logs
Any other documentation that relates to the
condition for which services were rendered
that skilled the patient for Medicare Part A
services in the Skilled Nursing Facility

The Appeal Package
Items to include
Diagnostic testing and lab work
Documentation of adjustment to HIPPS codes
resulting from MDS corrections
Signature log for all staff members
documenting in the medical record during the
dates in question, including printed name,
credentials and handwritten signatures

The Appeal Package
Each team member should review the
package as a whole
The team leader should have a final
look prior to submitting the appeal
PREP Letter
Proper Reimbursement Explanation Paper
Always keep a copy of the packet sent
to the reviewing agency

Appeal Rights
Redetermination
A review of the claim by the MAC utilizing
personnel who are different from the
personnel who made the initial
determination
The appellant (individual filing the appeal)
has 120 days from the date of receipt of
initial denial to file an appeal
A minimum monetary threshold is not
required to request a redetermination

Appeal Rights
Reconsideration
If the facility is dissatisfied with result of
redetermination, they may request a
reconsideration
A Qualified Independent Contractor (QIC) will
conduct the reconsideration
The reconsideration process is an independent
review of medical necessity by a panel of
physicians or other health care professionals
A minimum monetary threshold is not required to
request a reconsideration

Appeal Rights
ALJ Hearing
If at least $130 remains in controversy
following the QIC’s decision, the facility
may request an ALJ hearing within 60 days
of receipt of the reconsideration
The facility must also send a notice of the
ALJ hearing request to the QIC and verify
this on the hearing request form or in the
written request

ALJ Overview
After the redetermination and reconsideration
process, if at least $130 remains in
controversy following the QIC’s decision, the
facility may request an ALJ hearing within 60
days of receipt of the reconsideration
Combine claims to reach $130 if necessary
The facility must send a notice of the ALJ
hearing request to the QIC on the hearing
request form or in the written request

ALJ Overview
A letter to request the ALJ hearing
should simply highlight the most
pertinent reasons justifying
payment

Tip #6: Submit supportive
decisions

ALJ Overview
Submit a statement of justification
Submit the medical record
Submit any favorable decisions from the
QIC that support skilling the patient in
review

ALJ Overview
ALJ hearings are generally held by
video-teleconference (VTC) or by
telephone
If the facility prefers not to have a VTC
or telephone hearing, they may ask for
an in-person hearing, but they must
demonstrate the necessity for an in-
person hearing

ALJ Overview
The ALJ will determine whether an in-person
hearing is warranted on a case-by-case basis
Facilities may also ask the ALJ to make a
decision without a hearing (on-the-record)
CMS or its contractors may participate in an
ALJ hearing, but they must provide notice to
the ALJ and all parties of the hearing

ALJ Overview
ALJ will generally issue a decision within 90 days of
receipt of the hearing request
The timeframe may be extended for a variety of reasons
including, but not limited to:
The case being escalated from the reconsideration
level
The submission of additional evidence not included
with the hearing request
The request for an in-person hearing
The facility’s failure to send notice of the hearing
request to other parties and
The initiation of discovery if CMS is a party

ALJ Overview
If the ALJ does not issue a decision
within the applicable timeframe,
you may ask the ALJ to escalate
the case to the Appeals Council
level

ALJ
Office of Medicare Hearings and Appeals (OHMA)
Administrative law judge hearings will not be assigned to a
judge for at least two years
OMHA stopped assigning new hearing requests from
providers as of July 15, 2013
The weekly influx of hearing requests surged from an
average of 1,250 in January 2012 to more than 15,000 in
December 2013
Medicare Appellant Forum to provide updates to OMHA
appellants on the status of OMHA operations
http://www.hhs.gov/omha/omha_medicare_appellant_foru
m.html

ALJ
Hearing Preparation

Tip #7: Work as a team

ALJ Hearing Preparation
Appeal Process
Discuss and study CMS Guidelines
Discuss type of ALJ hearing (video,
phone, in person) to anticipate the
format
Goals of the Hearing
Inform the Judge of skilled services
Get the claim paid

Team Preparation
Medical record review
Outline of speaking points
Select a point person for the
hearing
Team input

The following team members are beneficial in this
process:
MDS Coordinator
Director of Nursing
Unit Managers (consider)
Restorative Nursing program Manager
Director of Therapy
Any therapy professionals involved in the patient’s care
Social Services
Dietary
Additional team members who participated in care

ALJ Hearing
Hearing Process
Prepare the facility designated hearing
room for video or phone hearings
Judge’s assistant will initiate the phone
contact (test phone lines and speakers)
Introductions
Statement by facility
Offer to fax any pertinent documents
discussed during the hearing

Tip #8: Be organized

ALJ Hearing
Organize documentation
Keep pertinent notes or forms at your
finger tips
Number the pages for reference
Have the staff that worked with patient
on the call

Tip #9: Be concise and use
plain language

ALJ Hearing
Speak respectfully, clearly, slowly
Provide a concise summary

ALJ Hearing
Be prepared to answer questions prepared
by the Judge
Why did the patient require skilled therapy
when they were hospitalized for a UTI?
Where does the medical record state that
continued therapy services were necessary
after the initial date in question?
Explain why skilled care continued although
the notes indicate the patient did not have an
exacerbation of medical condition?

ALJ Hearing
Be prepared to answer questions asked
by the Judge
When did the patient get discharged
from therapy services?
Why do the daily nursing notes state
the patient was ambulating ad lib, yet
physical therapy continued to provide
skilled treatment?

ALJ Success
37% favorable, 4% partially favorable
30% unfavorable
1% remanded
27% dismissed
Favorable decisions will result in
securing payment for services, plus
interest accrued

Tip #10: Practice makes
perfect

Keys to Success
Educate, Discuss and Prepare
Don’t Wait for Medicare Medical Review
Communicate to all Staff Medicare Skilled
Care Criteria
Refine Interdisciplinary Management of
Medicare Appeals
Establish and Maintain Peer Review and
External Review of Records to Assure
Insulation of Claims

Keys to Success
Raise Facility Awareness
Function as a TEAM
Communication
Organization

Keys to Success
Provide clinically appropriate care
Document
Medical necessity
Deficits
Outcomes
Meet technical requirements
Review entire medical record
Respond to ADRs timely

Questions/Answers
1 (800) 530 – 4413
cmullin@Harmony-Healthcare.com

Harmony Healthcare International (HHI)
For attending this seminar, you are eligible
for one of the following:
Free PEPPER Analysis
Free RUGS Analysis
Assess your facility against key indicators and national norms.
Contact us at:
RUGS@harmony-healthcare.com
Analysis is cost & obligation free
Harmony Healthcare International, Inc. 129Harmony Healthcare International, Inc.Copyright 2014 All Rights Reserved

Upcoming Seminars & Webinars
Copyright 2014 All Rights Reserved Harmony Healthcare International, Inc.
A Hands on Approach on How to Respond to
ADR’s & Appeals in the SNF
August 4, 2014: 8:30am-3:30pm
Harmony University, Topsfield, MA
Speaker: Carrie Mullin, OTR/L, RAC-CT, Claims Review Specialist
130
Online Registration Coming Soon!
http://www.harmony-healthcare.com/education-
training/schedule/
Visit our website for webinars, seminars & workshops!

Register online
http://info.harmony-healthcare.com/harmony2014
or by phone (978) 887-8919 ext. 13
Register Online

Top Ten Tips for a Successful ALJ Hearing

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (20)

Similaire à Top Ten Tips for a Successful ALJ Hearing

Similaire à Top Ten Tips for a Successful ALJ Hearing (20)

Plus de Harmony Healthcare International (HHI)

Plus de Harmony Healthcare International (HHI) (10)

Dernier

Dernier (20)

Top Ten Tips for a Successful ALJ Hearing