Without every “i” dotted and every “t” crossed on a claim, an overpayment may result, even if the services rendered were necessary for the patient. The appeals process is designed to give providers a chance to explain their case; it’s also a mechanism to make sure an audit has been properly conducted. Mistakes happen, even among auditors, who have the leverage to demand large amounts of money in refunds. As a result, there must be some checks and balances in the system, and if done correctly, the appeals process is that balance. The following tips may not help you win every appeal, but they certainly won’t hurt.
On January 9, 2018, CMS’ Innovation Center announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced). Under traditional fee-for-service payment, Medicare pays providers for each individual service they perform. Under this bundled payment model, participants can earn additional payment if all expenditures for a beneficiary’s episode of care are under a spending target that factors in quality.
Skilled nursing facility (SNF) providers are on the edge of their seats as they anticipate the Centers for Medicare & Medicaid Services' (CMS) consideration of a replacement for the Resource Utilization Group (RUG) system, which will change the way facilities are reimbursed for SNF Medicare Part A residents beginning FY2019. The Resident Classification System, Version 1 (RCS-1) will be the most significant change in the current reimbursement model, which has been in place for nearly two decades. Since being published in the Federal Register on April 27, 2017, providers and advocacy groups have submitted public comments and recommendations on the SNF prospective payment system (PPS) payment methodology proposed in the Summary of Advance Notice. Many concerns have been raised, especially regarding the reimbursement methodology for therapy services.