Jackson Davis HealthCare
Medicare Appeals &
Medicare Shadow Audits
Medicare Audit Defense & Medicare Appeals
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.
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 (MAC audits), Zone Program Integrity Contractors (ZPIC Audits), Medicaid Integrity Contractors (MIC audits) and a host of others are designed to crack down and eliminate fraud & abuse.
CMS is investing hundreds of millions of dollars in dozens of separate – but coordinated – enforcement efforts to force providers to adhere to Medicare rules & regulations. The target? Everyone. 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.
Now, more than ever, Medicare contractors are applying subjective opinions and inaccurate criteria in order to insure preconceived outcomes. Great providers are being bankrupted and 10,000s of people are losing their jobs to unscrupulous CMS auditors that are just trying to make a buck and increase their company's stock price.
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 - Over the past 25 years, Jackson Davis professionals have worked with providers nationwide to appeal 1,000s of Medicare overpayment issues and we have won close to 90% of all appeals. 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.
Medicare "Additional Documentation Request" 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.
2014 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 2014 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 - 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 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.
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 2014 Winter / Spring Upcoming 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.
January 7, 2014 - 2:00p - 3:30p EST
Physician E & M Coding and Use of Modifier 25 - Physician Offices & Hospitalist Inpatient Visits
This presentation will address a key focus area rolling out nationwide on the permanent Medicare audit program - Physician Evaluation & Management services & Use of Modifier 25 in both hospital and physician practice settings. Several previous Medicare audits, error evaluations, probes and directives have highlighted a wide range of challenges regarding the accuracy of E&M visit definitions. This discussion will provide an in-depth look at physician evaluation & management coding for inpatient hospitals services (CPT 99221 - 99223, 99231 - 99233) and established office visits (99211 - 99215).
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 January 6 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
January 21, 2014 - 2:00p - 3:30p EST
Inpatient Rehabilitation Facility - 2014 Medicare Coverage Criteria
This presentation will address Medicare Coverage Criteria for Inpatient Rehabilitation Facility admissions. We will discuss the IRF "medical necessity" criteria and the full range of CMS documentation requirements for inpatient rehab providers. This will be a detailed discussion of Medicare Benefit Policy Manual, Chapter 1, Section 110 and how MACs are applying coverage criteria to their audits.
Please send your registration request and contact information to us via e-mail at email@example.com. Registrations must be received no later than January 20 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
February 4, 2014 - 2:00p - 3:30p EST
Home Health Agencies - Homebound Status, Certification, Skilled Nursing Care & Physical Therapy
This presentation will address Home Health Agencies and ramped up CMS efforts to attack perceived overpayments to providers. Nationwide, ZPICs, RACs and MACs are out in full force to conditionally deny cases based upon homebound status, lack of certification, unnecessary skilled nursing care and medically inappropriate physical therapy services. This is an OUTSTANDING presentation for home health providers and will focus on Medicare coverage criteria, responding to Medicare additional documentation requests and the filing of home health appeals.
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 February 3 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
February 18, 2014 - 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 email@example.com. Registrations must be received no later than February 17 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
March 4, 2014 - 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, therapy services 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 firstname.lastname@example.org. Registrations must be received no later than march 3 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
March 18, 2014 - 2:00p - 3:30p EST
Hospice Care - Terminal Illness Certification... 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... provider payments for the certification of 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 actually 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 email@example.com. Registrations must be received no later than March 17 and you will receive an e-mail confirmation with sign-on information and password. The cost is $295 per healthcare provider.
2014 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-audit 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 firstname.lastname@example.org.