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Course Description

Medicare claims are subject to inspection by Medicare Contractors. The approach prior to submission of claims as well as managing the pre- and post payment requests is critical to maintain revenue streams. The key to preventing denials is documentation of skilled services provided. Additionally, the key to documenting skilled services provided is understanding the Medicare requirements for coverage. Medicare Contractors send providers additional development request (ADR) letters requesting additional documentation. Providers who do not respond, are untimely or submit insufficient documents will be subject to repayment of Medicare dollars.

When the claim is finalized, the claim will have paid in full, or part, or denied. What happens when a claim is denied? There is a high percentage of facilities across the country that do not respond to the notice of denied claims. This results in the organization losing valuable revenue for services provided.

There are various steps involved in the management and claims appeal process that must be executed with precision for appeals to be successfully processed.  Does the team have a check list for efficiency? Is all of the terminology understood?  Are the services billed in compliance with Medicare Regulatory guidelines?  Answers to these questions and Appeal solutions will be discussed. Avoid the consequences of the facility submitting poor documents and learn how to avoid a technical denial in this session.


The Centers for Medicare & Medicaid Service (CMS) in conjunction with the Office of Inspector General establishes laws by which the skilled nursing facility proprietors must abide.  The legal ramifications of missteps in the claim submission and appeal process are significant and can disable an organization.

Medicare claim medical reviews are a focus of the government and place facilities at risk for denied claims. Understanding documentation requirements will play a critical role in ensuring accurate and appropriate reimbursement. This course will provide a step by step approach to ensure accurate and appropriate reimbursement.

An overview of how the interdisciplinary team can successfully navigate through claim reviews and each step of the Appeal process will be presented.  Determinations that are unfavorable must be reviewed for accuracy with initiation of the appeal process in a timely and efficient manner. Multiple denied claims can be an indication of faulty communication and billing disruptions within your organization. Ultimately facilities who fail to respond with competence could be subjected to further governmental investigations resulting in Corporate Integrity Agreements.

This course will highlight successful strategies for the interdisciplinary team to effectively address denials for single and multiple claims.  The process for claim appeals can be daunting and a lack of precision can result in an organization being subject to probe reviews and governmental investigations.  The program will allow Directors and clinicians to establish best practices for successful processing of Medicare claim denials.


  • Medicare Skilled Criteria
  • Claim Prepatory steps
  • Defining the Roles of the Team
  • Claim submission
  • Tracking strategies
  • Preventing denied claims
  • Steps to Appealing Denials
  • Denied claim approaches
  • Successful Outcomes


  • Attendees will be able to state the 5 steps in the Appeal Process
  • Leaders will be able to identify a plan for educating the team on claim tracking
  • Attendees will identify 4 essential roles for the SNF team in appealing denied claims
  • Attendees will be able to compose appeal statements
  • The learner will be able to identify techniques for educating staff in relationship to Medicare Probe Reviews and RAC Audits
  • The learner will be able to state documentation errors exposing centers to fraudulent claim submissions
  • Attendees will state the Medicare Part A skilled care qualifiers


  • Administrators
  • Nurse Managers / Nursing Staff
  • Business Office Managers
  • MDS Coordinators
  • Social Service Department
  • Rehabilitation Directors
  • Therapy professionals


Elisa Bovee has been working in the healthcare environment advocating for patients through education and clinical guidance for over 20 years.  With a Masters degree in Occupational Therapy she has managed a national operations team performing audits and analysis across the US for skilled nursing and healthcare providers. Her expertise includes clinical solutions for treatment of patients with multiple complexities, Compliance Programs, Regulatory guidelines, development of Education programs, Reimbursement and skilled documentation for nursing and therapy professionals. Managing claims through the Contractor Request and Denial phases is Ms. Bovee’s forte.  Elisa presents programs nationally targeting all interdisciplinary groups seeking guidance and clarity on a multitude of Regulatory and clinical topics. Elisa has written and contributed to articles for numerous national trade publications.

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