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Just when you thought it was safe

On March 30th, CMS suspended most Medicare Fee-For-Service (FFS) medical reviews because of the COVID-19 pandemic. In a recent COVID-19 Provider Burden Relief  FAQs, CMS stated that regardless of the status of the public health emergency, pre-payment and post payment medical reviews will resume beginning August 3, 2020.

These reviews/audits include those conducted by MACs under the Targeted Probe and Educate program as well as those conducted by Supplemental Medical Review Contractor (SMRC) and Recovery Audit Contractor (RACs).

The best security blanket to help avoid financial losses at the hands of the auditors is to make sure your systems are in place, your processes are being followed, staff are educated on billing requirements, and for some, developing a relationship with a third party billing reviewer.  Third party reviews can ensure billing accuracy, that the supporting documentation for your claim is producible and you receive the reimbursement that matches the level of care you provided.

Another process that often leads to misfortune is an organizations Additional Documentation Request (ADR) process. Broken systems can lead to incomplete or inappropriate documentation being sent, lack of timely response and in the end significant reimbursement losses. Unfortunately, this is a common issue that can be rectified by having systems in place that provide guidance for off-shift staff when they receive an ADR, designating an individual that holds responsibility for retrieving the necessary documentation and ensuring it is reviewed for accuracy and totality prior to being sent.

Now is a good time to review these systems before the pencil is sharpened.  We have already seen an uptick in Medicare Advantage Program ADR’s and denials.  With this in mind, the announcement from CMS, and the reimbursement challenges we are facing during the pandemic, we feel it is critical for facility’s to be prepared.  Please reach out  if you feel you need assistance in these areas or would like to talk more about our third party billing reviews. Our reimbursement experts can quickly conduct an analysis of these areas, provide recommendations and the tools & education you need to protect your reimbursement.


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