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CMS Update - Sharp Rise in Denials for SNF Claims

CMS issued an update regarding what appears to be a sharp increase in the denial rate for Skilled Nursing Facilities (SNFs) as reported in the 2015 Comprehensive Error Rate Testing (CERT) Report. The CERT Report showed denials increasing from 6.9% reported in 2014 to 11% in 2015.

What did CMS attribute as the cause of this significant increase? DOCUMENTATION

Here are some documentation requirements that CMS reported for the increase in denials resulting from missing or incomplete certification/recertification including:

  • Statement must contain need for skilled services that can only be provided in SNF/swing-bed on a daily basis for a condition patient was treated for in prior hospital stay
  • Must include physician’s dated signature (printed name if signature is illegible)

As to re-certifications, the documentation should include:

  • Expected length of stay
  • Explanation if continued need for services is for a condition that arose after SNF admission
  • Any plans for home care

Lesson to be learned: DOCUMENTATION MATTERS!

It is important that providers understand what CMS requires, and providers ensure that their documentation includes the necessary statements to avoid denials. We can help providers be proactive in providing adequate documentation to avoid denials. However, should the providers encounter the need to appeal their denied payments, we can help with the appeal process.

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