Jackson Davis HealthCare
Medicare Audit Defense
& Medicare Appeals
(303) 586-5003
support@cmsaudits.com
Medicare Audits & Medicare Coverage Criteria (RAC Audits / ZPIC Audits / MAC Audits / DOJ Audits)
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.
CMS is investing millions of dollars in dozens of separate – but coordinated – enforcement efforts to force providers to adhere to Medicare rules & regulations. Unfortunately, although the vast majority of providers support the aggressive pursuit of Medicare fraud & abuse, wide ranging challenges face those same providers when striving to achieve 100% compliance with Medicare coverage criteria.
The modern CMS auditing effort is both far reaching and technologically advanced. Coordinated efforts of law enforcement, Medicare Recovery Auditors, Medicare Administrative Contractors, Program Safeguard Contractors, Zone Program Integrity Contractors, Medicaid Integrity Contractors and a host of others are designed to crack down and eliminate fraud & abuse.
In addition to now having thousands of contracted individual 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.
Top 5 Barriers to Medicare Compliance
Ok, let’s be honest. While the barriers to Medicare compliance are too numerous to address in the body of this discussion, the following would be generally considered as the TOP 5:
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 and 100s of disparate CMS payment criteria / Medicare coverage criteria resources are just a few major focus areas.
2) Providers nationwide are making documentation, coding & billing decisions based upon an array of information and insight from sources other than CMS. While these sources may provide an important advisory role they don’t have authority over Medicare payments. 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 nearly as easy as it sounds. With a 10% unemployment rate and potential fraud implications associated with Medicare 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 mean major repayments and reduced cash flow for the foreseeable future.
4) The nation’s best attorneys – like Robert Benvenuti, the former Inspector General of Kentucky - are advising clients to make every effort to adhere to Medicare coverage criteria. However, arguing vague notions of “medical necessity” can be a boon for unscrupulous attorneys and consultants. There are far too many consultants and other attorneys 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 – simply, 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? It’s really not. 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 one of the areas where Jackson Davis HealthCare professionals come into play. JDH offers the ultimate resource for providers looking to understand and integrate real-time CMS Payment Criteria / Medicare Coverage Criteria at the heart of their organizations. Our staff does the heavy lifting for you. With over 25,000 hours of dedicate Medicare coverage criteria and our industry-leading expert analyses, JDH provides the ultimate solution to overcoming Medicare compliance barriers.
Regulatory & Legislative Resources
Jackson Davis Healthcare has committed almost 20 years to evaluating CMS evidence-based outcomes and clinical payment criteria, Medicare coverage criteria, Medicare Conditions of Participation documentation requirements, Medicare audit focus areas and the effective & efficient submission of Medicare appeals. In addition, the Jackson Davis HealthCare staff has compiled the nation's most comprehensive data warehouse of Medicare audits & Medicare appeals documentation resources available to providers.
Medicare audits pose one of the largest financial and operational challenges to healthcare providers since the initiation of DRGs almost 30 years ago. Providers around the nation are working hard and committing substantial resources to completing developing and maintaining CMS payment criteria, completing internal audits and establishing a framework to track CMS auditor requests and subsequent Medicare appeals.
The following is a small sample and "first tier" set of RAC regulatory and legislative resources and it is designed to provide a starting point for all providers tackling this important issue.
Coding/DRG/Health Information Management
Quality Improvement Organizations (QIO) HPMP Resource Documentation
As part of the 9th Statement of Work (SOW) for Quality Improvement Organizations (QIOs), CMS transitioned the primary responsibility for the enforcement of inpatient hospital claim policies and Medicare coverage criteria to RACs nationwide. As of July 31, 2008, CMS elected to no longer contract with QIOs across the country for implementation or maintenance of the Hospital Payment Monitoring Program. As a direct result, QIOs closed down their HPMP programs in late 2008 and removed detailed supporting documentation from publicly available websites.
Now the very good news! Prior to July 31, 2008, Jackson Davis HealthCare professionals worked diligently to compile over 500 HPMP supporting documents from QIOs nationwide! As a result, Jackson Davis is making these vital documents available within the 2011 Medicare Audits & Medicare Appeals Guide. These documents are core to a wide range of Medicare auditor "medical necessity" challenges and critical for providers responding to CMS payment criteria, Medicare coverage criteria and medical necessity challenges. They are the absolute backbone of insuring compliance with each Medicare primary focus areas.