Jackson Davis HealthCare
Medicare Audit Defense
& Medicare Appeals
(303) 586-5003
support@cmsappeals.com
Medicare Appeals - Internal Medicare Program Integrity Audits - Medicare Compliance Advisory Services
Jackson Davis HealthCare (JDH) is one of the nation's leading providers of Medicare appeals, proactice Medicare program integrity audits and retained Medicare compliance advisory services. Jackson Davis HealthCare has completed Medicare program integrity audits and provided Medicare appeals support for providers ranging in from $10.0B multi-hospital health systems and major academic medical centers - to inpatient rehabilitation facilities, skilled nursing facilities, home health agencies and hospices - to physician practices, HME suppliers and $25M critical access hospitals.
Jackson Davis HealthCare (JDH) is the leading national resource for CMS payment criteria, Medicare coverage criteria, proactive Medicare program integrity audits, 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.
Although the Medicare audit target issues may vary based upon a provider's reimbursement structure and billing patterns, CMS payment criteria and Medicare coverage criteria are applicable across the spectrum. We absolutely and unconditionally guarantee that our clients are at the forefront of insuring compliance with Medicare coverage criteriia & related CMS payment criteria, reducing Medicare fraud and adhering to CMS established medical necessity requirements.
We are Medicare Compliance Geeks
CMS is combining Medicare audits (RAC audits, ZPIC audits. etc.) 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 Program Integrity Audits
Medicare Retained Compliance Advisory Services
Medicare Appeals - RAC Audits, ZPIC Audits, OIG Audits, MAC Audits, DOJ Audits
2011 Medicare Audits & Medicare Appeals Guide
2011 Medicare Self-Audit & Medicare Appeals Tools
CMS Clinical Documentation & Coding Compliance Management
Case Management / Utilization Review / Discharge Planning
Charge Master Development and Compliance
Medicare Cost Report Development and Compliance
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 Medicare & Medicaid auditors to force the implementation of evidence-based standard of care practices.
Claims or opinions of Medicare audit focus areas & the Medicare appeals process being guided by subjectivity or vague Medicare guidelines 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 Appeals
Over the past 25 years, Jackson Davis professionals have worked with providers and attorneys nationwide to address 10,000s of CMS overpayment issues. As your unwavering advocate, Jackson Davis HealthCare (JDH) leads the nation in building CMS criteria-based cases and developing winning Medicare appeals. In order to maintain attorney-client privilege throughout the appeals process, JDH partners with leading national and international law firms to establish codified work-product relationships. We have established working relationships with the nation's best attorneys and work with each provider to hand-select the most experienced attorney(s) for their specific circumstance.
It is critical that providers and legal counsel have an in-depth understanding of applicable CMS Payment Criteria & Medicare Coverage Criteria - medical necessity issues, claim submission guidelines, site or setting limitations, coding variables, billing parameters and required clinical documentation elements. Jackson Davis HealthCare is the undisputed leader in 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.
Are you facing Medicare challenges related to a RAC audit, ZPIC audit, MAC audit or other Medicare audit? Call JDH clinical and compliance professionals today and let us go to work for you!
Provider-Initiated, Internal 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 include a pre-determined sampling of 20 - 1,000 patient encounters or admissions. Each Medicare case is pre-screened and carefully selected based upon Medicare audit 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)
Emergency Room Visits and Modifier 25
Discharge Status Code Assignment
Inpatient Rehabilitation Facility Admissions
HME and Use of KX Modifier
Skilled Nursing Facility Admissions
Hospice Admissions
Home Health Episodes of Care
Physician E&M Coding and/or Modifier 25
Physical Therapy Episodes
Based upon the number of records being reviewed and scope of the Medicare audit focus areas, proactive Medicare 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.
Medicare PI audits & Medicare appeals traditionally include detailed input from our team of board-certified physicians, legal nurses, case management specialists, Medicare attorneys and dedicate Medicare compliance staff. Each Medicare PI audit is supported by an extensive & wide range of formal documentation resources authored by or reviewed on behalf of the Centers for Medicare & Medicaid Services.