Jackson Davis leads the nation in building winning Medicare appeals cases.  As your unwavering advocate, we assist providers in building rock-solid Medicare appeals cases, defending against financial recoupment and responding to potential Medicare fraud allegations.  Using Medicare coverage criteria as the foundation, our professionals assist in all aspects of Medicare audit defense.  Our professionals dedicate every day to understanding, documenting, synthesizing and applying Medicare coverage criteria to cases conditionally denied by Medicare contractors.

Medicare Appeals / Medicare Shadow Audits

Over the past 27 years, Jackson Davis professionals have worked with providers nationwide to appeal 10,000s of Medicare overpayment issues.  Jackson Davis partners with providers to analyze, develop & build winning Medicare appeals cases.  RAC appeals, ZPIC appeals, MAC appeals, USAO appeals, SMRC appeals - 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.  A sample of our top 20 focus areas includes:

  • Diagnostic Laboratory Testing
  • DME supplies (billing and medical necessity)
  • Emergency Room visit criteria and CPT code selection
  • Excisional Debridement Impacted MS-DRGs
  • Extensive O.R. Procedures Unrelated to PDX
  • Facet Joint Injections
  • Home Health visits & admissions (homebound status, skilled, therapy and medical necessity)
  • Hospice admissions (medical necessity – Part A & GIP)
  • Inpatient Rehabilitation Facility admissions
  • Lumbar Spinal Fusion
  • Major Joint Replacement (hips & knees)
  • One-Day Stays (chest pain, heart failure, syncope, etc.)
  • Outpatient physical therapy visits & KX modifier
  • PCI / ICD / Pacemakers (surgical procedures in wrong setting)
  • Physician E&M coding (99211 - 99215, 99223 and 99233)
  • Portable Radiology visits & billing
  • Septicemia diagnosis code sequencing
  • Skilled Nursing Facility admissions (Part A & Part B)
  • Use of modifier 25
  • Wound care clinic and procedure billing

Transaction Due Diligence Audits

In today's dynamic Medicare audit environment, purchasing the assets and accepting the liabilities of any provider can be risky.  Jackson Davis is trusted by some of the nation's largest health systems and we have completed due diligence evaluations associated with the purchase of $1.0B+ enterprises.  We can help you identify the primary areas for concern - perform detailed coverage criteria audits and physician reviews - quantify potential losses and then assist with the implementation of compliance enhancing solutions.

Bundled Payments for Care Improvement Compliance Audits (BPCI Compliance Audits)

Medicare audit denials (RAC audits, ZPIC audits, etc.) can result in retroactive recoupment of up to 4 years of BPCI payments and cause unparalleled damage to valued relationships between awardees, episode initiators and/or conveners.  Along with a wide range of other Medicare pay-for-performance (P4P) initiatives, BPCI is clearly a major focal point for CMS.  BPCI offers tremendous opportunities for providers to strengthen relationships, solidify market share, simplify billing processes and improve overall cost-effectiveness.  With all these benefits front-and-center, BPCI contract participants have extraordinary long-term incentives to mitigate future Medicare audit recoupment risks (especially Models 2, 3 & 4).

Jackson Davis assists awardees and contracted initiators / conveners in completing both periodic and annual, independent BPCI compliance audits.  These compliance audits are designed to identify risks for Medicare audit recoupment of BPCI inpatient services and they are based solely upon codified Medicare documentation, billing, coding and medical necessity coverage criteria.  Independent BPCI audits are absolutely crucial to insuring the ongoing financial viability and long-term success of BPCI relationships. 

Medicare Program Integrity Audits (Mock Audits)

Jackson Davis assists providers in completing proactive, medical record audits versus Medicare coverage criteria - Medicare Program Integrity audits (or "Mock" Audits). Each mock audit is based on codified Medicare coverage criteria and cases are pre-screened and carefully selected based upon current or anticipated Medicare audit focus areas.  Once the initial mock audit is complete, our industry-leading staff works directly with the provider to evaluate, understand and consider alternatives for achieving enhanced Medicare coverage compliance.

Medicare "Additional Documentation Request" (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 Medicare auditor requests for documentation.  NO ONE will give you a better chance to address and eliminate additional Medicare audit threats.

Medicare Consulting Services

Providers nationwide retain Jackson Davis for periodic mock audits, transaction due diligence, compliance advice or professional guidance 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.  Hospital appeals, physician appeals, SNF appeals, home health appeals, hospice appeals, IRF appeals and HME supplier appeals - call us today and put Jackson Davis to work for you!

How Can We Help?

​​Jackson Davis HealthCare

​RAC Audit Appeals | ZPIC Audit Appeals | UPIC Audit Appeals
(303) 586-5003 or support@jdhcare.com