What do Successful Medicare Appeals Have in Common? (Knicole Emanuel’s Recent Blog)

I have gotten quite a few emails and calls from readers (and their attorneys) about audits focused on skin subs and debridements. Many practitioners simply do not have sufficient documentation to defend the denied claims and honestly, there’s not much that can be done if the information required to support the claim is just not in the chart. For the rest, the audit is focused on whether the documentation provided meets the auditors’ interpretation of a given Local Coverage Determination (LCD). However, check out #3 below which is very interesting!

Medicare attorney Knicole Emanuel has been posting information relevant to wound care practitioners on her blog. Ms. Emanuel’s latest post (which should be read in its entirety) lists the things that successfully Medicare appeals have in common for wound care practitioners:

Wound care practitioners can be successful IF:

1. Records demonstrate that that the care provided was medically necessary.

1. • At the Administrative Law Judge (ALJ) level, a podiatrist successfully defended an extrapolated overpayment case involving debridement and other podiatric services by demonstrating the medical necessity of care provided to 77 beneficiaries (in other words, a subset of the total claims in dispute as part of an “extrapolation”)

2. Detailed records are available addressing the way that the standard of care was met.

1. • A practitioner won an appeal at the ALJ because the clinical record had details of the vascular assessment (Remember that there are rules around whether you can provide entirely new documentation to the ALJ if you failed to produce the relevant records at an earlier stage – but keep reading!)
   • Documentation clearly supported the argument that conservative treatment had been performed and failed

3. The auditor’s reasons for denial were vague and failed to provide fair notice of the issues in dispute.

1. • The Appeals Council accepted delayed physician certifications where contemporaneous records demonstrated physician involvement and medical necessity.
   • Supplemental evidence was be considered when earlier review stages provided incomplete or shifting rationales for denial.

Ensure your documentation is complete is BEFORE you get audited. If your regional Medicare contractor does not have an LCD pertaining to wound care, debridement, or skin substitute use – you should become familiar with other MAC LCDs because auditors can use them!

Feel free to email me about your ongoing experience with the evolving reasons for claim denial and the outcome of your audit. The goal is to educate other practitioners to do a better job of documentation and a better job of ensuring that the complete “story” is provided to the auditor.

Caroline

Related Articles:

Useful Information on Medicare Audits: First Coast Wound Care Checklist for TPE

Useful Materials for Responding to a Medicare Audit: Part 1

Medicare Audit Info: Palmetto TPE on Hyperbaric Oxygen Therapy (HBOT)

The High Cost of Playing Documentation Defense Against Medicare Audits

Overzealous Medicare Audits

Medicare Audits – the World’s Most Expensive Scavenger Hunt (Read and Think “Skin Substitutes / Cellular Tissue Products / CAMPS”)

Check Out Attorney Knicole Emanuel’s Post on Medicare Audits of “Skin Substitutes”!

Medicare Auditors Are Not Wound Care Specialists: Why Providers Win Appeals When the Full Story Finally Gets Read – Blog Post by Knicole Emanuel

The post What do Successful Medicare Appeals Have in Common? (Knicole Emanuel’s Recent Blog) appeared first on Caroline Fife M.D..