Managing Medicare Appeals

Inpatient rehabilitation is not a field for the faint of heart. We have faced many challenges during our tenure on the continuum of care and now we face one more: Medicare audits. In the whirlwind of the day-to-day provision of care, you now have to find time to provide a compelling argument why the services your facility provides are medically necessary. Where do you begin? How will you ever find the time? Don't worry, we can help.

When your facility is asked to provide documentation for review by the Fiscal Intermediary or Recovery Audit Contractor, the way you respond is vital to achieving payment on the claims. The process begins with the additional documentation request and continues with determination, redetermination, reconsideration, administrative law judge hearing, Medicare appeals council proceedings, and an appearance at the federal district court. Every stage of the process is different, and your rebuttals should speak to your unique audience. An informed response and attention to detail are the keys to your success.

Fleming-Advanced Outcomes Design Consulting has expertise with managing the Medicare Appeals Process from ADR through the ALJ. With over 10 years of experience in managing Medicare denials, we offer a solution that is efficient, proven, and affordable.

Contact us when you have received your first ADR.

Initially we will review your program to analyze operations and patient flow. We will help you organize your documentation so you can put your best foot forward during the first review of your facility. Next, we will write your appeal letters, which will argue the specific reasons for denial and defend all of the points of medical necessity outlined in the Medicare Benefit Policy Manual for inpatient rehabilitation hospital services. Since different levels of appeal have different audiences, we will tailor the letters at each level of appeal where new information may be added. Additionally, the medical record will be organized and flagged to assist the CMS auditors in finding the documentation supporting medical necessity in the chart.

Our goal is to give you tools to successfully manage the appeals process on your own. We will provide education and consultation that will allow you to do so effectively and efficiently. After analyzing your operations and documentation, we will provide a review of strengths and weaknesses followed by recommendations, a plan for improvement, and staff education.

When you notify us early in the process, we will have the opportunity to complete a site visit and have your first appeal letters ready to post within 30 days of our initial visit.

Our team has years of personal experience in arguing appeals through the ALJ level of the Medicare Appeals process in inpatient rehabilitation facilities, skilled nursing facilities, and outpatient rehabilitation.

An engagement with Fleming-Advanced Outcomes Design Consulting begins with a site visit.

Site Visit

• Program review - operations, admissions process, IRF-PAI completion
• Medical necessity documentation review

Redetermination appeals packet

• Appeal letter - with consideration to your Fiscal Intermediary's Local Coverage Determination
• Sample letter to send to the beneficiary to get them to write CMS in support of the facility and to write their congressional representatives
• Sample letter to send to the referring physician to get them to write CMS in support of the patient's admission to your facility
• Analysis of your FI/RAC's overturn rate at redetermination

Reconsideration appeals preparation

• Appeal template
• Analysis of the QIC's overturn rate at reconsideration

ALJ Preparation

• ALJ documentation formatting
• Staff and physician preparation documents
• Analysis of the ALJ's overturn rate

Appeals training and staff education

Prices vary depending on the Documentation Review findings and engagement of Fleming-Advanced Outcomes Design Consulting at prior levels of appeal. Additional travel and administrative expenses apply.

Contact Lisa Werner at (240) 386-7876 or email  lwerner [at] flemingaod.com  to begin the process.

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