Jackson Davis HealthCare
Medicare Audit Defense
& Medicare Appeals
(303) 586-5003
support@cmsaudits.com
Medicare Audits, Medicare Appeals & Medicare Coverage Criteria
Over the past decade, CMS (the Centers for Medicare & Medicaid Services) has ramped up efforts to insure 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 CMS payment criteria or Medicare coverage criteria.
The modern Medicare auditing effort is both far reaching and technologically advanced. Coordinated efforts of law enforcement, Medicare Recovery Auditors (RAC Audits), Medicare Administrative Contractors, Program Safeguard Contractors, Zone Program Integrity Contractors (ZPIC Audits), Medicaid Integrity Contractors and a host of others are designed to crack down and eliminate fraud & abuse.
CMS is investing millions of dollars in dozens of separate – but coordinated – enforcement efforts to force providers to adhere to Medicare rules & regulations. The target? Everyone. Hospitals, physicians, inpatient rehabilitation facilities, skilled nursing facilities, hospices, home health agencies, HME suppliers and physical therapists are all under fire. In addition to now having thousands of contracted individual Medicare auditors under the CMS umbrella, the government is utilizing leading-edge database technology and integrated business logic to assist in the day-to-day review of millions of electronic Medicare claims for payment. Providers can no longer fly under the radar of the Medicare audit process. If you submit electronic claims for payment, you are instantly being “audited” for the services rendered.
How Can Jackson Davis Help?
As your unwavering advocate, Jackson Davis HealthCare (JDH) leads the nation in completing proactice Medicare program integrity audits and developing winning Medicare appeals. For over 25 years, Jackson Davis HealthCare professionals have dedicated everyday 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 Program Integrity Audits (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 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!
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.
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.
___________________________________________________________________________________________________________
Upcoming Medicare Audits & Medicare Appeals Webcasts
August 23, 2011 - 2:00pm - 3:00pm 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 support@cmsaudits.com. Registrations must be received no later than August 22. You will receive an e-mail confirmation with sign-on information and password prior to August 23. The cost is $159 per healthcare provider or health law attorney.
September 6, 2011 - 2:00pm - 3:00pm EST
CMS Appeals for Healthcare Providers - Applicability of the Treating Physician Rule & Other Legal Arguments
This presentation will address CMS efforts to stop Medicare fraud, Medicare audits, Medicare appeals and the applicability of the "treating physician rule". CMS and a wide range of judicial findings have determined the relative weight to be given to attending physician testimony, Medicare coverage criteria, independent medical evidence and other issues in pending Medicare appeal matters. With Medicare RAC audits, Medicare ZPIC audits and Medicaid Integrity Contractor audits (MIC audits) rolling out nationwide and 100,000s of Medicare appeals being anticipated annually, it is critical that providers understand prior Medicare Appeals Council and U.S. court findings relating to these very important issues.
Please send your registration request and contact information to us via e-mail at support@cmsaudits.com. Registrations must be received no later than September 5. You will receive an e-mail confirmation with sign-on information and password prior to September 6. The cost is $159 per healthcare provider or health law attorney.
September 20, 2011 - 2:00pm - 3:00pm EST
Physician E&Ms / Wound Care Clinics / Emergency Room Visits - Use of Modifier 25
This presentation will address a key focus area that is rolling out nationwide on the permanent Medicare audit program - Physician Evaluation & Management services / Wound Care Clinic services / Emergency Room Visits - Use of Modifier 25. Several previous CMS audits, error evaluations, probes and directives have highlighted a wide range of challenges regarding the accuracy of ER visit definitions. This discussion will provide an in-depth look at physician evaluation & management coding, wound care clinic visits, ER visit definition, billing, claim submission requirements and the most recent CMS directives regarding modifier 25.
Please send your registration request and contact information to us via e-mail at support@cmsaudits.com. Registrations must be received no later than September 19. You will receive an e-mail confirmation with sign-on information and password prior to September 20. The cost is $159 per healthcare provider and health law attorney.
___________________________________________________________________________________________________________
Top 5 Barriers to Medicare Compliance
While the barriers to Medicare compliance are too numerous to address in the body of a webpage discussion, the following would be generally considered as the TOP 5 challenges when facing Medicare audit issues:
1) First and foremost, the Medicare regulatory environment is so dynamic that even the most highly trained and skilled professionals struggle with day-to-day updates. Decentralized and potentially conflicting guidance from dozens of CMS contractors, continually changing regulations, 100s of disparate CMS payment criteria / Medicare coverage criteria resources and 10,000s of individual rules & regulations are just a few major focus areas.
2) In order to focus on their day-to-day practices and still stay on top of major compliance issues, providers nationwide have been forced to make documentation, coding & billing decisions based upon guidance from sources other than CMS. While the vast majority of these sources are legitimate and knowledgable, others may not necessarily have a complete understanding of Medicare coverage criteria. Some of these include consultants, professional associations, commercial admission screening or “medical necessity” criteria, peers, lawyers, certification organizations, physician advisors and software vendors.
3) Making changes isn’t as easy as it sounds. With a nearly 10% unemployment rate and potential Medicare fraud implications associated with billing practices, it can be very difficult to gain buy-in from key decision-makers. No one wants to be the messenger when it can result in repayments and reduced cash flow for the foreseeable future.
4) The nation’s best healthcare attorneys and health law firms - and there are some terrific Medicare attorneys out there today - are advising clients to make every effort to adhere to Medicare coverage criteria. However, others are promoting "legal / procedural" arguments in an attempt to circumvent or mitigate Medicare regulations. There are far too many unscrupulous attorneys and other consultants looking to tap into provider emotions and cash-in on provider retainers.
5) Discussions and education of medical staff can be very stressful and is often avoided for political (or personal survival) reasons.
Overcoming the Barriers to Medicare Compliance
No real magic here... embrace CMS Payment Criteria / Medicare Coverage Criteria as the core foundation of your financial infrastructure. Put another way, don’t let anything - other than documented CMS & CMS contractor guidance - be the foundation for your decisions relating to potential Medicare beneficiary coverage & payment. Sound simple? Any Medicare provider will tell you that it is anything but simple.
In order to “embrace” Medicare coverage criteria, you first have to know what it is. In order to know what it is, you have to find it, evaluate it, understand it, synthesize it and then do something with it. Oh yeah, you also have to convince everyone around you that it is the right thing to do and hope that the coverage criteria doesn’t change before you can get it implemented.
This is where Jackson Davis HealthCare (JDH) professionals come into play. JDH is the ultimate resource for providers looking to fully adopt CMS Payment Criteria / Medicare Coverage Criteria, address potential Medicare audit challenges and effectively tackle pending Medicare appeals. Our staff does the heavy lifting for you. We dedicate 1,000s of professional hours annually to identifying, understanding and synthesizing Medicare coverage criteria and we will assist you in overcoming Medicare compliance barriers.