Medical Claim Denied Stamp Shows Unsuccessful Medical Reimbursem


“Money was never a big motivation for me, except as a way to keep score. The real excitement is playing the game.” ~ Donald Trump


Skilled Nursing Facilities (SNF) strive for quality of care, quality of life, helping residents return to the community and providing compassion while helping those peacefully transition from this life. Our jobs are hard and the restrictions we have to work under are burdensome. So why do we do it? The real excitement for caregivers is helping those who cannot help themselves!

Improper Medicare payments to skilled nursing facilities have increased from 4.8% to 7.7% between 2012 and 2013 due to the SNF’s failure to obtain physician and NPPs certification and re-certification statements. If the physician/NPP certification and re-certification process is not timely and does not provide all of the medical necessity statements by the physician/NPP justifying the need for the skilled level of care, SNFs will be at risk for improper payments when faced with an audit. Improper documentation practices will contribute to receiving a denial for medical necessity followed by facing the potential for the resident’s entire skilled stay to be recouped.

Working through the appeal process takes an immense amount of time and attention to detail, not to mention resources to track and hike through the appeal process. Absence of a “clean claim” is most common reason for denials in SNFs. These oversights include missing modifiers, missing or inaccurate ICD-9 codes, improper coding, etc. Stopping the denials before they happen is the challenge we all face. In its’ FY 2014 Agency Financial Report, The Department of Health and Human Services reported an overall fee-for-service error rate of 12.7 percent, representing $46.3 billion in improper payments. ₁

If an Additional Development Request (ADR) is made from the Medicare contractor, ensure you have a denials/appeal team established in the SNF to tackle the layers of the process. Including all necessary documentation for the auditor to review is crucial. Stopping a denial at the ADR level will preserve payments and avoid denials which could negatively affect your cash flow and increase resources for appeals.

Did you know that claim denial rates are projected to increase by 100% to 200% in the early stages of coding ICD-10?₂ Your nursing staff and therapy provider must be committed to transparency and working together to ensuring the nursing and therapy documentation supports medical necessity and reflects the skills of a nurse and therapist.


Healthcare is a constantly changing world. Continue focusing on quality and value based service and at the same time, keep the dollars you rightfully deserve for the care provided. If you find you are constantly being reactive rather than proactive, stop the insanity and review systems. Continuing to do the same thing and expect different
results is simply crazy.

• Be Proactive!
• Review nursing and therapy documentation frequently.
• Provide ongoing training to nursing staff regarding accurately recording ADLs.
• Supply ongoing training to therapy staff pertaining to accurately recording treatment provided.
• Ensure all necessary documentation is consistently placed in the medical record.

• Establish a denial team in your facility.
• Commit to clean claim submission.
• Improve documentation quality.
• Demand compliance with an effective Triple Check Process.
• Build a committed partnership with Therapy!



We are committed to doing everything we can to improve the lives of our residents. Being a part of a pro-active, transparent, and seamless team is vital to the success of our future care giving abilities.


Medicare Denials_table


₁Connolly Healthcare:
₂Claim Denials: 15 ways to fight back; Medical Economics;


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