Welcome back to the final article in our short series on resolving Medicare denials.  If you missed the previous posts on reopening claims or resubmissions and appeals, you may want to go back and read those first.  Otherwise, let’s wrap it up with a practical discussion about the strategy of making a choice in the context of procedural differences unique to each resolution option.

Engagement Time (shortest to longest)

Suppliers have a limited amount of time to engage each of the escalation options. After a certain point, the age will limit the available options. For example, if a post payment review recoups a two-year-old claim, the date of service will be too old to resubmit, but the denial breathes new life into the appeal and reopen pathways. Some denials can only be appealed, and if suppliers fail to escalate the appeal within 120 days of the denial, they must write off the balance.

Engagement times are as follows:

• Appeal – Suppliers only have 120 days from the denial date to engage a formal appeal.
• Resubmit – Suppliers have one year from the date of service to resubmit a claim.
• Reopen – Suppliers have one year from the last denial date to request either a telephone or written reopening (even if the date of service is now past timely filing).

Processing Time (shortest to longest)

In terms of processing time, telephone reopenings and claim resubmissions offer clear advantages when compared to written reopenings and appeals. Preparing any written document just takes longer in most cases.

General processing times are as follows:

• Telephone reopening – The MACs often process requests in as few as five days.
• Resubmit – Electronic claims often process in 14 days.
• Written reopening – The MACs often process requests within 15-30 days.
• Appeal – The MACs often process requests in 30-45 days.

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The nature of the denial, however, may narrow the field of available options. Some denials can only be appealed (See Denial Types below).

Supplier Preparation Time (shortest to longest)

Preparation time is a finite resource, and as such, suppliers should consider it thoughtfully. Clearly, we should keep prep time minimal, but suppliers cannot afford to pursue an option that doesn’t fix the problem. Appeals take the most time to prepare, but they may be the only means to resolve the denial, if not the best means to get the point across.

Typical preparation times are as follows:

• Resubmit – 1-2 minutes to fix the error in the billing system.
• Telephone reopening – 10 minutes to engage the customer service representative and make the change.
• Written reopening – 15 minutes to prepare the document and fax the request.
• Appeal – 20-30 minutes to assemble documentation, make the case, and fax the request.

Denial Types

Sometimes the characteristics of the denial itself can limit escalation options.

Rejected claims do not have appeal or reopen rights. They must be resubmitted. These claims typically present on EOBs with a MA130 remark code.

Medical necessity denials, on the other hand, cannot be reopened or resubmitted. They must be appealed. Examples of medical necessity denials include CO-50 (medical necessity), CO-150 (level of service), and CO-151 (frequency of service). If the supplier doesn’t appeal the denial within 120 days of the EOB notification, they must write off the open balance.

And so, a basic understanding of each option … the situations in which it applies, the effort required to execute … goes a long way toward an efficient billing operation. At the risk of sounding clichéd, work smarter, not harder.
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Welcome back to our short series on options for resolving Medicare denials. If you missed last week’s article on reopening claims, you can catch up here. Otherwise, let’s talk about two more options: resubmitting and appealing claims.

When to Resubmit a Claim

As a general rule, if claims can be reopened, they can also be resubmitted as long as the service date is timely and the original claim denied. Resubmissions of partially paid claims, however, will deny as a duplicate; these corrections must proceed through the reopenings channel. Resubmission ultimately reduces the biller’s time investment because it is often faster to resubmit a claim than to navigate the IVR to speak with a service representative. Suppliers should resubmit claims that deny for:

• Missing:
  • Narratives (e.g. patient owned equipment or miscellaneous code).
  • Primary payment information.
  • Pricing modifiers (e.g. NU, RR, KH, KI, KJ).
  • Certificates of Medical Necessity (CMNs).
  • Facility details (e.g. when the place of service is not 12 “home”).​
• Expired or invalid procedure codes.
• Expired or invalid diagnosis codes.
• Physician PECOS error.
• Critical elements that cause rejection (look for an MA130 remark code).

Ideal candidates for resubmission:

All the denials from the reopenings list (where the service date is timely and the MACs denied payment).

16 denials with N265 and N276 remark codes (missing information PECOS name errors). Correct the physician’s first initial and last name in your billing system to match the PECOS record, then resubmit the claim.

16 denials with an M60 remark code (missing information missing CMN). Confirm the CMN is not missing critical elements, then reattach the CMN, and resubmit the claim.

107 denials (service not identified). Add a narrative: “For use with patient owned DME (HCPCS) delivered on (month/year),” and resubmit the claim.

176 denials (prescription not current). Add a narrative: “Please extend the CMN to allow for remaining payments due to break in service,” and resubmit the claim.

The fine print: Suppliers must resubmit all rejected claims with an MA130 remark code. After the supplier links the missing element and resubmits the claim, the DME MACs usually process the claim within 14 days of receipt. Contractually, the DME MACs can take up to 30 days to process a claim, but they rarely take that long. Suppliers must resubmit claims within 365 days of the date of service. Suppliers cannot resubmit medical necessity denials or partially paid claims.

When to Appeal a Claim

Suppliers should formally appeal denials related to:

• Medical necessity (missing medical records from an audit).
• Missing policy-specific modifiers (KX, CG modifiers).
• Missing or invalid Advance Beneficiary Notice or modifier combination (GA, GK modifiers).
• Diagnosis codes that do not support medical need.
• CMN errors and denied CMNs.
• Excessive quantities.
• Same or similar equipment.

Ideal candidates for appeals:

50 denials (medical necessity). When Medicare audits suppliers, medical reviewers often find errors in the supporting medical records. Always call to find out why the claim denied and what medical record is at fault. Appeal the decision with records that fill in the gaps.

150 denials (level of service not supported). Look up same or similar history on the Medicare portal to determine if the patient received a similar item from your company and another supplier within the useful lifetime. Appeal the decision if you have documentation to support the previous product failed after the useful lifetime (generally 5 years) or if loss, theft, damage, or change in the beneficiary’s medical condition can justify the early replacement.

151 denials (frequency of service). This denial typically applies to recurring supplies with frequency limitations. Determine how many units are billable in a 3-month period and look up same or similar on the Medicare portal to determine when the patient received a similar product. Appeal the decision if you have documentation to support the claim does not overlap a prior product or if loss, theft, damage, or change in condition can justify the early service.

The fine print: The DME MACs usually process appeals within 30-45 days. Contractually, the MACs have up to 60 days to process appeal requests. Suppliers must file the initial appeal within 120 days of the original remittance date.

Next week, we will talk about strategies for optimizing the use of each of the denial resolution strategies.
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The MACs offer four potential options to resolve denials: telephone reopenings, written reopenings, claim resubmissions, and appeals. When suppliers understand the unique attributes of each pathway, they can use them with confidence to optimize results.

Over the next several weeks, we are exploring each option and the circumstances for which each is most appropriate.  This week, let’s talk reopenings.

When to Reopen a Claim

If you can easily ask a representative to change “this” to “that”, a reopening is likely appropriate. Medicare advises suppliers to use the reopening process to correct clerical errors such as:

• Units of service.
• Service dates.
• Submitted amounts.
• Procedure codes.
• Diagnosis codes.
• Modifiers (excluding KX, GA, GZ, and GY which must be appealed).
• Incorrect, duplicate denials.

 Ideal Candidates for Reopenings

109 denials with N538 remark code (claim not covered by payer, inpatient stay). This solution works for new equipment setups where the beneficiary is just getting out of the hospital. If the patient was discharged within 48 hours of the delivery, call and change the service date to match the discharge date.

182 denials (invalid procedure modifier for date of service). This solution applies to capped rental claims with KH or KI modifiers. Use the applicable MAC portal to determine how many rental months have paid. Call and change the claim modifier to match the modifier corresponding to the next available payment in the sequence (KI for the second and third payment, or KJ for the fourth through 13th payment).

The fine print: Telephone reopenings usually process in five days and written reopenings process within 15-30 days. Contractually, the DME MACs have up to 60 days to process any reopening, but they rarely take that long. Suppliers must request reopenings within 365 days of the remittance date, in some cases extending the payment timeline beyond the service date. When clerical errors result in partially paid claims, suppliers should always use the reopening process to make the correction. Reopenings are not permitted for medical necessity denials or rejected claims with an MA130 remark code.

CGS Tool

A new tool on the CGS website may help suppliers choose the best option for specific circumstances. Simply enter the denial reason and remark code from a remittance notice, and the tool will explain the root cause of the denial and advise the next course of action.

Typically, billers have multiple escalation pathways to choose from. Denial characteristics, volume, preparation, and processing time should all factor into the decision process. While there is no substitute for experience, learning the basics and incorporating available tools will help medical billers efficiently navigate denial resolution.

Due to a recent automated audit by the RAC, or Recovery Audit Contractor, suppliers are receiving overpayment letters for same and similar equipment. While the current audit is searching for multiple back braces paid within five years for the same beneficiary, other products are vulnerable to this type of recovery … PAP supplies, catheters, and knee braces, come to mind.

Integrating an efficient search process into the intake process for all Medicare products is a cost-effective way to reduce recoupment exposure.

Use Web Portals to Search for Same and Similar Equipment Before Delivering any Medicare Product

The MACs’ portals allow suppliers to check for same and similar items for all HCPCS. In the past, suppliers had to call and speak with a Medicare representative to get history on prosthetics, orthotics, and supplies (A codes and L codes). Thankfully, this is no longer the case.

A quick training document or screencast for the entire staff on the electronic same and similar search features will ensure consistent application by current and future employees. In addition to basic portal navigation, consider including strategies to find all instances of same and similar equipment. For example:

• Use wildcard searches on the CGS portal (e.g. E* will return all E codes).
• Search HCPCS ranges on the Noridian portal (e.g. B0000 - B99999).

If no same and similar equipment is found, save a print out of the results to the patient file to document your due diligence.

Beneficiaries Relocated From Other States

If a beneficiary has a previous address in another state, the portal for the current jurisdiction may not capture all prior activity. To ensure a complete claim history, suppliers should call the DME MAC servicing other states the beneficiary has called home.

Beneficiaries With Prior Services

If prior equipment is identified in the search, suppliers should evaluate the circumstances and supplement intake procedures accordingly to ensure payment. The beneficiary may be eligible for early replacement in cases of lost or stolen equipment, equipment damaged beyond repair, or changes in medical need, to name a few. Suppliers should utilize claim narratives and replacement/repair modifiers on related claims (e.g. RA, RB) to convey justification for early replacement.

If early replacement is not justified, suppliers should secure an advanced beneficiary notice (ABN) before delivery.

Simple, thorough, and consistently applied same and similar searches do not have to be an impediment to speedy deliveries. A small investment in each setup can, however, mean the difference between profit and loss.