While nursing homes across the nation are seeing a significant decline in COVID-19 cases, providers are reporting a sharp increase in medical review. The most prominent  activity includes RAC (Recovery Auditors Contractor) reviews and TPE (Targeted Probe & Educate) reviews from the MACs (Medicare Administrative Contractors). Nursing homes can monitor active topics posted by their local RAC and MAC.  In this week’s blog, learn more about the current active medical review topics and keys to successful outcomes when submitting ADRs…


Currently medical review activity includes SNF Medical Necessity with audits underway by various contractors of both PDPM and post-pay RUG claims, as well as Medicare Part B therapy service reviews.

Keys to Medical Review Success

  1. Review Proactive’s Tips for an Effective ADR Response.
  2. Know your designated medical review contact. In the midst of staffing shortages, outbreaks, etc., most review entities will allow grace periods or grant extensions to submit documentation packets. Providers should keep in close contact to notify the medical review contractor of any anticipated delays in documentation submission.
  3. Conduct documentation rehab documentation reviews, specifically in regards to delivery of therapeutic exercise (97110). At least 5 of 7 MACs are conducting TPEs based on documentation and billing practices surrounding this treatment code. Not only should providers be engaging in routine documentation reviews, but also regularly incorporate documentation standards of practice into staff education and training sessions. Therapy staff should be familiar with Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) that govern the provision, coding and documentation of rehab services.
  4. Review the medical record to ensure certification requirements are met. The record must include required certification/recertification documentation to support Medicare Extended Care Services as outlined in the Medicare Benefit Policy Manual (CMS IOM Publication 100-02, Chapter 8, Section 40) and Chapter 4, Section 40 – Physician Certification and Recertification of Extended Care Services. In the event claims are lacking a complete, formal cert/recert documentation, or failing to meet physician signature requirements in a timely manner, based on the Medicare guidance found in 40.5 – Delayed Certifications and Recertification for Extended Care Services, providers should consider obtaining delayed certification and/or recertification statements using information contained in the medical record. Proactive has consistently found delayed certification via physician attestation statements to be acceptable under Medicare Medical Review.
  5. Respond quickly to denials. As you process a denial, the details of the care are usually fresh and it is more efficient to develop the defensiv position statement(s) outlining your argument for overturning the denial. Keep in mind, RACs offer a time period for open discussion. This is typically completed via desk review and decisions are often overturned at this level without being forwarded to the MAC. In the event the MAC does issue a demand letter informing the provider of an overpayment, a redetermination request must be submitted within 30 days in order to stop recoupment from occurring. The standard timeframe for submitting the Redetermination appeal is 120 days.
  6. Understand key documentation rules and guidance. Providers shouldn’t assume that reviewers are experts in payer policies. Engage clinical and regulatory experts in denial reviews in order to best advocate for the care and services rendered, and to defend claims.

Contact Proactive to schedule a remote medical necessity coding and documentation audit or to learn more about Medical Review support services including ADR preparation and Appeals managment.


Stacy Baker, OTR/L, RAC-CT, CHC
Director of Audit Services

Learn more about the rest of the Proactive team.