The Healthcare Provider's #1 Medicare Audit Defense & Medicare Appeals Resource
Medicare Audit Defense & Compliance - ZPIC Appeals - RAC Appeals - CMS Program Integrity Resources

"Mock" Medicare Audits - Medicare Appeals - Medicare Compliance Advisory Services

Jackson Davis HealthCare (JDH) is the leading national resource for CMS payment criteria, Medicare coverage criteria, proactive Medicare clinical & compliance reviews, Medicare Conditions of Participation documentation requirements, CMS billing compliance, physician expert testimony, Medicare appeals & Medicare legal support services.  Comprised of board-certified physicians, nurses, billing compliance professionals and former hospital executives - JDH is widely recognized as the nation's leading expert on Medicare audits and Medicare appeals.

We absolutely and unconditionally guarantee that our clients are at the forefront of insuring compliance with Medicare coverage criteria & related CMS payment criteria, reducing Medicare fraud and adhering to CMS established "medical necessity" require.  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 - Over the past 25 years, Jackson Davis professionals have worked with providers and attorneys nationwide to appeal 1,000s of Medicare overpayment issues.  JDH partners with leading national and international law firms to maintain attorney-client privilege, establish codified work-product relationships and develop winning Medicare appeals.  We have established working relationships with the nation's best attorneys and they work hand-in-hand with JDH staff to bring you the best, most experienced and most cost-effective solution for your Medicare appeal needs.

Medicare Program Integrity Audits ("Mock" PI Audits) - Jackson Davis HealthCare works closely with providers to complete proactive, detailed & comprehensive Medicare Program Integrity audits (or "Mock PI Audits").  Each Medicare PI audit is centered on documented, codified CMS payment criteria and Medicare coverage criteria for selected focus areas and traditionally includes a pre-determined sampling of 10 - 500 patient encounters.  Each encounter is pre-screened and carefully selected based upon Medicare current or anticipated audit focus areas.  Let JDH physicians, nurses and Medicare compliance professionals go to work for you!

CMS Compliance Advisory Services - Providers nationwide retain JDH for retained monthly counsel 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 Medicare geeks.  From our physicians to our nurses to our compliance reseach team, we are in your corner and available 24/7 for your CMS compliance needs.

JDH Clinical, Compliance & Legal Support Services - Medicare Audits & Medicare Appeals

CMS is combining Medicare RAC audits (as well as Medicare ZPIC audits) with pay-for-performance (p4p) initiatives in a classic "carrot and stick" approach to advancing and solidifying evidence-based medicine as the foundation for the future of the Medicare program.  Jackson Davis HealthCare professionals work with hospitals, inpatient rehabilitation facilities, physician practices, skilled nursing facilities, hospices, HME suppliers, physical therapists, home health agencies and health law firms nationwide in a wide range of Medicare audit focus areas:

                Medicare Compliance Audits
                Medicare Audit Clinical & Compliance Assessments
                Submission of Medicare Appeals
                2011 Medicare Audits & Medicare Appeals Guide
                2011 Medicare Self-Audit & Appeals Tools
                CMS PI Warehouse
                CMS Clinical Documentation & Coding Compliance Management
                Case Management / Utilization Review / Discharge Planning
                Charge Master and Medicare Cost Report Compliance
                RAC Task Force Development and Audit Tracking Processes
                RAC Appeals and Quarterly Compliance Audit Outsourcing

Hospitals, physicians and other healthcare providers are facing the imminent adoption of Medicare's new evidence-based reimbursement structure, implementation of wide ranging EBM policies & procedures and the introduction of concepts such as evidence-based coverage, pay-for-performance and value-based purchasing.  In order to insure compliance and make a clean break from the past, CMS is using high-profile RAC auditors to force the implementation of evidence-based standard of care practices.

Claims and opinions of Medicare audits & the Medicare appeals process being buried in subjectivity and vague interpretations of medical necessity couldn't be farther from the truth.  Outdated notions and concepts of "soft" Medicare billing and claims submission requirements have been left in the past.  The game has changed - very real and defined CMS payment criteria, Medicare coverage criteria, required Conditions of Participation documentation and the application of CMS evidence-based outcomes rule-the-day.

Medicare Program Integrity Audits ("Mock" PI Audits)

Jackson Davis HealthCare works closely with providers to complete proactive, detailed & comprehensive Medicare Program Integrity audits (or "PI Audits").  Each Medicare PI audit is centered on documented, codified CMS payment criteria and Medicare coverage criteria for selected focus areas and traditionally include a pre-determined sampling of 10 - 500 patient encounters.  Each encounter is pre-screened and carefully selected based upon CMS auditor approved focus areas, anticipated focus areas, and other CMS ongoing audits and outcomes.

Sample focus areas might include:

        Short Stays - Chest Pain & Chest Pain Related Diagnoses
        Respiratory Care Diagnoses with Ventilator MS-DRGs
        Excisional Debridement Impacted MS-DRGs
        Extensive O.R. Procedures Unrelated to PDX
        PCI / Implantable Cardioverter Defibrillators (ICDs) / Pacemakers
        SNF Admissions & 3-Day Acute Stay Medical Necessity
        Emergency Room Visits and Modifier 25
        Discharge Status Code Assignment
        Inpatient Rehabilitation Facility Admissions
        Skilled Nursing Facility Admissions
        Hospice Admissions
        Home Health Episodes of Care
        Physician E&M Coding and/or Modifier 25

Based upon the number of records being reviewed and scope of the Medicare audit focus areas, Jackson Davis HealthCare PI audits are traditionally completed over a 2 - 12 week time frame.  Each in-depth evaluation incorporates a stratified sampling of Medicare audit focus areas and includes 5 major assessment components - billing, coding structure, documentation, claim submission & medical necessity.  All Medicare audit & Medicare appeals services include detailed evaluations by our board-certified physicians, nurses, case management specialists, legal services staff, attorneys, Medicare reimbursement and billing compliance professionals.

Our experienced Medicare coverage criteria auditors, Medicare attorneys, Medicare audit and Medicare appeals staff, physicians, nurses and former hospital executives are all dedicated to providing you with an unmatched professional services experience.  Each assessment finding is supported by an extensive & wide range of formal documentation resources authored by or reviewed on behalf of the Centers for Medicare & Medicaid Services.