Physician Certifications Causing Medicare Denials

Physician orders and certifications for level of care are a required component of Medicare claim coverage.  A physician must certify that the resident needs a skilled level of care, then order the skilled services that are eligible for Medicare reimbursement and ultimately payment of the Part A stay. According to CERT reviews, the claims are being denied based on the requirement that the physician must not only sign the certification within the specified time frame, but must also include a statement as to the condition for which the resident requires ongoing care, for how long the resident is anticipated to need ongoing care, and the potential need for home care upon discharge.

Some facilities utilize physician certification forms, although there is no requirement for a specified form.  If using the forms, the form has a space to enter this information.  Our ProCare team often conducts audits for members and has noted the same findings as the CERT process.  Members are good at getting the doctors to sign and date the forms timely, but they are not always good at getting ALL the required information onto the form.  This has become a goldmine for reviewers who seek to deny claims.

CMS has published guidance in MLN Matters SE1428 related to the requirements of the physician certification/recertification process.  If you have any questions about your compliance with the process, or would like an audit of your process, our ProCare team can assist you.

Contact: Michelle Synakowski, msynakowski@leadingageny.org, 518-867-8850