Medicare RAC Auditors Expand Coding, MS-DRG assurance and Medical Necessity Reviews. CMS Targets Providers Nationwide With Expanded Medicare Recovery Audits (RAC Audits)
In an effort to move-the-bar and collect on perceived overpayments to providers, The Centers for Medicare and Medicare Services (CMS) is taking aggressive strides to accelerate the acceptance of evidence-based health care and lighten the load of a strained national budget. After spending the past 30 years collecting and analyzing outcomes data from internal programs (CERTs, HPMPs, QIOs, etc.), both Congress and CMS have committed unprecedented resources to enforce evidence-based coverage policies and stop Medicare fraud.
Over the past decade, CMS (the Centers for Medicare & Medicaid Services) has ramped up efforts to guarantee the taxpayer that healthcare providers are solely paid for services rendered that (1) meet requirements as originally established within the Social Security Act and subsequent regulations, (2) meet Medicare provider contractual obligations (Conditions of Participation) and (3) meet Medicare coverage criteria.
The problem? The vast majority of healthcare providers are good people that obey the law and make every effort to adhere to multiple layers of conflicting and seemingly arbitrary Medicare coverage criteria for payment. While for-profit, Medicare audit contractors are building businesses and selling out to the highest bidder, providers a caught in a giant web of never-ending audits of their services. Hospitals, physicians, home health agencies, hospices, DME suppliers, inpatient rehab facilities, physical therapists.... all are facing daily challenges of operating under enormous governmental scrutiny and overwhelming paperwork requirements.
In addition to the highly touted and widely publicized RAC Audits - Medicare ZPIC audits, OIG audits, DOJ audits, Medicaid Integrity Contractor audits and the Medicare One PI system are all just samples of the latest initiatives focused on provider payments. However, CMS is adopting Medicare recovery audits (or RAC audits) as the first real tangible effort to push hospitals, physicians and other healthcare providers down a path of revolutionizing the clinical practice of medicine. Using a classic "carrot and stick" approach, CMS has combined clinical pay-for-performance (P4P) incentives and value-based purchasing initiatives (the carrot) with the strong arm of RAC medical collection agencies (the stick) to insure providers are doing their part to facilitate a more nationalized, evidence-based healthcare structure.
How Can Jackson Davis Help?
As your unwavering advocate, Jackson Davis HealthCare (JDH) leads the nation in assisting healthcare providers facing Medicare compliance challenges. For over 25 years, Jackson Davis HealthCare professionals have dedicated every day to understanding, documenting, synthesizing and applying Medicare Coverage Criteria for cases being considered for Medicare audits and Medicare appeals - RAC appeals, ZPIC appeals, DOJ appeals, MAC appeals, MIC appeals or individual Medicare beneficiary appeals.
Medicare Appeals / Medicare Shadow Audits - Over the past 25 years, Jackson Davis professionals have worked with providers nationwide to appeal 1,000s of Medicare overpayment issues and win close to 90% of all cases. JDH partners with providers to analyze, develop & build winning Medicare appeals cases. Our board-certified physicians, legal nurse auditors and industry-leading compliance staff are unmatched in Medicare audit defense and the submission of winning Medicare appeals. Simply put, NO ONE will give you a better chance to succeed at your Medicare appeals.
2013 Medicare Self-Audit Templates - Are you looking to build a rock-solid internal audit & compliance program using Medicare coverage criteria as a foundation? Have you been conditionally denied payment from a Medicare contractor and want to build winning appeals? The 2013 Medicare self-audit templates are perfect for use by internal auditors and compliance professionals when reviewing potential Medicare focus areas and building winning Medicare appeals. These detailed, self-audit templates are now available for purchase by healthcare providers nationwide.
Mock Medicare Program Integrity Audits (Mock PI Audits) - Jackson Davis HealthCare assists providers in completing proactive, medical records audits versus Medicare coverage criteria - Medicare Program Integrity audits (or "Mock" PI Audits). Each Medicare PI audit is based on documented, CMS payment criteria and Medicare coverage criteria for selected focus areas and may include a sampling of 10 - 500 patient encounters. Each encounter is pre-screened and carefully selected based upon Medicare current or anticipated audit focus areas.
Medicare "Additional Documentation Request" Response (RAC auditor ADR response) - A provider's initial ADR response is a critical stage of the Medicare audit process. Jackson Davis professionals are experts at developing a cohesive and winning approach to responding to RAC auditor requests for documentation. NO ONE will give you a better chance to address and eliminate additional Medicare audit threats.
Internal Audit & Medicare Physician Advisor Program Development - Are you looking for a helping hand in developing or revamping your internal audit or Medicare physician advisor programs? Are you looking for a reliable resource to work as a true partner in the process of adopting a more structured foundation built on Medicare coverage criteria? Are you uncomfortable about facing prepay audits or want peer review of your external physician advisor group? Jackson Davis is the solution. Our board-certified physicians really do understand Medicare coverage criteria and they work closely with our legal nurses and regulatory team to bring compliant solutions to providers everyday.
CMS Compliance Advisory Services - Providers nationwide retain JDH for monthly audits, compliance advice or on a project-by-project basis. Our staff is highly experienced and our knowledge and application of Medicare rules and regulations is unmatched in the industry. We are true Medicare compliance geeks. From our physicians to our nurses to our compliance research team, we are in your corner and available 24/7 for your CMS compliance needs. Call us today for help with any medicare appeal issue - hospital appeals, snf appeals, home health appeals, physician appeals, hospice appeals and DME supplier appeals.
Medicare Audits & Medicare Appeals - $295 Webcasts - FY 2013 Fall / Winter Events
Join our industry-leading Medicare audit defense team and Medicare coverage criteria professionals for the nation's best Medicare audits and Medicare appeals webcasts! Call or e-mail us today for registration at email@example.com or (303) 586-5003.
October 22, 2013 - 2:00p - 3:30p EST
The Medicare Appeals Process for Healthcare Providers - How to Win!
This presentation will address issues associated with Medicare audit defense strategies, Medicare appeals and Medicare shadow audits - RAC appeals, ZPIC appeals, DOJ appeals, OIG appeals, MAC appeals, Medicare overpayment determinations and the Medicare appeals process. Through 2013, Jackson Davis has assisted providers in winning almost 90% of all Medicare appeals... and we will be in your corner!
As CMS continues to ramp up auditing efforts, providers nationwide are spending tens of millions of dollars on legal fees, repaying hundreds of millions of dollars to CMS for conditional denials and being exposed to potential Medicare fraud allegations. This discussion will provide an in-depth look at the Medicare appeals process and explore a wide range of opportunities for providers to proactively build winning Medicare appeals (RAC appeals, ZPIC appeals, etc.). The old days of soft regulations and provider education are over - it is absolutely vital that providers understand how the game has changed.
Please send your registration request and contact information to us via e-mail at firstname.lastname@example.org. Registrations must be received no later than October 21 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
November 5, 2013 - 2:00p - 3:30p EST
Medicare Auditor Targeting of Skilled Nursing Facilities (Part A & Part B) - SNF "Medical Necessity", MDS Documentation & Therapy Services
Under fire from Medicare audits, SNFs can be highly susceptible to losses from missing documentation, "medical necessity" requirements and challenges relating to appropriately billed MDS components for Medicare Part A and Part B coverage. This presentation will address a wide range of topics including responding to Additional Documentation Requests from CMS and CMS contractors, applicability of acute stay documentation, developing SNF appeals, performing self-audits and the major target areas where providers struggle to win ZPIC audit cases.
Please send your registration request and contact information to us via e-mail at email@example.com. Registrations must be received no later than November 4 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
November 12, 2013 - 2:00p - 3:30p EST
Hospice Care - How long is too long?
This presentation will address one of the most frustrating and "grossly inappropriate" audit focus areas on the current CMS workplan... the denial of care for terminally ill patients that live longer than 6 months. Medicare contractors - and ZPIC auditors in particular - have attacked providers who care for terminally ill patients that live longer than their diagnosis-driven, average life expectancy of 6 months. Not only are these Medicare auditors arbitrarily denying cases where patients live longer than average, they are extrapolating the outcomes into the millions of dollars for select hospice providers.
Please send your registration request and contact information to us via e-mail at firstname.lastname@example.org. Registrations must be received no later than November 11 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
November 19, 2013 - 2:00p - 3:30p EST
Percutaneous Coronary Intervention (PCI) & ICD Surgical Procedures - Inpatient or Outpatient?
This presentation will address one of the primary Medicare audit focus areas and specifically considers CMS challenges to performing these surgical procedures in the "wrong setting". Critical issues such as the Medicare Inpatient Only list, inpatient admitting criteria, documentation requirements and case management will all be discussed in detail. This will be a great discussion for Case Management, HIM and financial staff.
Please send your registration request and contact information to us via e-mail at email@example.com. Registrations must be received no later than November 18 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
December 3, 2013 - 2:00pm - 3:30pm EST
CMS Targeting of Skilled Nursing Facilities (Part B Only) - In-depth Look at Therapy Services & the KX Modifier
This presentation will address a key focus area that is on the national Medicare audits / ZPIC audits / MAC audits / RAC audits radar - SNF Part B therapy services & use of the KX modifier. SNFs are being targeting for overuse of Part B services and outcomes are being extrapolated by ZPICS and MACs on a daily basis. This discussion will provide an in-depth and detailed look at CMS investigation outcomes, MAC target areas, Medicare coverage criteria, NCD / LCD requirements, billing, claim submission requirements and the most recent CMS directives regarding modifier KX.
Please send your registration request and contact information to us via e-mail at firstname.lastname@example.org. Registrations must be received no later than December 2 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per SNF provider.
2013 Medicare Audit Defense & Medicare Appeals - Self-Audit Templates
Medicare self-audit templates and Medicare supporting documentation are now available for purchase by healthcare providers and healthcare attorneys nationwide. These are the perfect solution to proactively preparing for Medicare RAC audits, Medicare ZPIC audits, Medicaid Integrity Contractor audits and a wide range of other CMS audit initiatives!
Jackson Davis HealthCare, the nation's leading resource for Medicare audit defense & Medicare appeals, has invested thousands of hours in the documentation of CMS payment criteria, Medicare coverage criteria & development of Medicare self-audit templates for each RAC audit focus area. These Medicare self-audit templates are backed by over 10,000 CMS and CMS contractor documents and provide the nation's most comprehensive resource for the evaluation of Medicare audit focus areas and the preparation of Medicare appeals.
The Medicare self-audt templates are perfect for use by internal auditors and compliance professionals in proactively reviewing potential RAC audit cases and when considering the filing RAC appeals. The following is a small sample of Medicare self-audit templates that are available for purchase by healthcare providers:
PCI / ICD / Pacemakers (surgical procedures in wrong setting)
Major Joint Replacement (orthopedic hips / knees)
Home Health Agency admissions (homebound status and medical necessity)
Skilled Nursing Facility admissions
Short stays (chest pain & chest pain related diagnoses)
Pneumonia diagnosis code sequencing
Physician E&M coding
Hospice admissions (medical necessity)
Respiratory care with ventilator diagnosis code sequencing
Inpatient Rehabilitation Facility admissions
Outpatient physical therapy visits
Use of modifier 25
Wound care clinic and procedure billing
Emergency Room visit criteria and CPT code selection
HME supplies (billing and medical necessity)
Excisional Debridement Impacted MS-DRGs
Extensive O.R. Procedures Unrelated to PDX
Portable Radiology visits & billing
Neulasta billing & documentation
Septicemia diagnosis code sequencing
Single and multi-facility pricing options are available. Contact one of our Medicare audit defense team members or Medicare appeals compliance professionals with any questions and place your order request at (303) 586-5003 or e-mail us directly at email@example.com