Harmony Healthcare International (HHI) Offers Insights on How to be “Denial-Free”

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Five Simple Steps to Prepare for and Respond to Claims Denials

This is no time to be in denial about denials

Auditors have stepped up PPS and Medicare Part B claims reviews at skilled nursing facilities (SNFs) throughout the country. The intensification of the review process reflects the Centers for Medicare and Medicaid Services (CMS) commitment to detecting, deterring and preventing Medicare fraud and abuse.

“This is no time to be in denial about denials,” said Kris Mastrangelo, OTR/L, LNHA, MBA, President and CEO of Harmony Healthcare International (HHI), “CMS has increased activity in this area and has contracted an increased number of reviewers to rout out any fraudulent activity.”

Harmony Healthcare International (HHI), the leader in compliance and reimbursement consulting and education, offers five easy steps to help providers proactively prepare for reviews and ensure fair and accurate reimbursement of services.

1.    Communication – Timing is everything. Quickly notify all team members when an Additional Development Request (ADR) or Unfavorable Notice of Determination is received. Incorporate discussions regarding claim status into an existing meeting so involved team members are updated regularly.

2.    Policy and Process – Establish a facility protocol for managing all requests and appeals. Sign off sheets for directors and managers to confirm participation in the process are highly recommended.

3.    Organization – Submit documentation and files that are numbered, paginated and provide a table of contents for the location of each piece of data. Check lists for inclusion of all necessary data will assist with this step in the process. Keep a copy of all documents that are submitted at every step of the appeal process.

4.    Champions – Select a point person to be your facility “champion” who can assist with the orchestration of all medical record submissions. Alert: Don’t be late! Late submissions = DENIALS.

5.    Track the Progress – Read all correspondence received from the Medicare Contactors. Keep a tracking sheet of all dates when there is verbal or written communication regarding each individual claim.

Precision and timing are the cornerstones of a successful review. CMS considers medical review contractors as being responsible for detecting, deterring, and even preventing Medicare fraud and abuse. In this capacity, the auditor is directly responsible for operating areas such as investigation, case development, administrative solutions, and referral to law enforcement.

“Being on top of your game is essential, we recommend researching claims, identifying patterns and instituting education and training that is focused and directed,” said Mastrangelo, “Everything ties back to the medical record, staff must understand how documentation supports the daily skilled care provided by nurses and therapists.”

Providers cannot afford to be remiss on charting of care provided to Medicare patients. The records must reflect each service coded on the MDS and billed on the UB-04.

“Frequent training and communication to staff regarding the accountability for the written reports on each patient can prevent denials from Medicare contractors and support revenue generated from appropriate skilled care provided,” added Mastrangelo.

About Harmony Healthcare International

Harmony Healthcare International (HHI) was founded in 2001. With headquarters in Topsfield, MA, Harmony Healthcare International (HHI) serves clients in the skilled nursing, acute care, home health and assisted living markets with operational and compliance consulting, training and educational programs and talent enrichment services. With a staff of accomplished HealthCARE Specialists who serve as consultants to For-Profit, Not-For-Profit, Standalone and Multi-Facility Chains across the country, Harmony Healthcare International (HHI) has been ranked among the top 5,000 fastest growing private companies in the U.S. for 3 consecutive years by Inc. Magazine. Harmony Healthcare International, “We C.A.R.E. About Care.” Visit us at:

Media Contacts:
Jon A. Di Gesu
Vice President of Marketing and Public Relations
(O) 978.887.8919 (C) 603.770.5731

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