Home Health Medicare Audits June 27, 2013 F.O.R.C.E. Healthcare Resources, LLC (Founded on Regulatory Compliance and Ethics)
About F.O.R.C.E.? Home Health Consulting Firm – Founded 2005 Services Provided: 1. Home Health Billing Webinars 2.Home Health Outsource Billing 3.Home Health Outsource Medical Coding 4.Home Health Billing Clean-up/Recovery Projects 5.Home Health Operation / Process Consulting 6.Home Health Financial Consulting 2
Contact Information F.O.R.C.E Healthcare Resource, LLC. –Website: Terri Ready, COO -Direct: ext Mobile: Lynn Alley, Office Manager –Direct: ext
Additional Development Request (ADR)
ADR Documentation must be as complete as possible If the claim is denied due to documentation submitted, incomplete or missing you can appeal If documentation is received by the MAC within 45 days of the ADR date their system will deny the claim Providers who do not respond in a timely manner will be candidates for increased or continued medical review
Recovery Audit Contractors (RAC)
RAC To identify and correct Medicare improper payments. Auditors review claims on a post-payment basis Recovery Audits look back three years from the date the claim was paid If they are withholding $ due to a recovery audit the remit will have remark Code N432 There are 3 ways to repay the overpayment identified. Check out the appeal process at this web address: ppealsprocessflowchartAB.pdf
RAC There are several issues that separate the RAC audits from the traditional Medicare audit process The objective of the RAC audit is not the same as a traditional Medicare audit CMS is paying RAC auditors approx. 10% of every dollar identified and recouped If a Recovery Auditor finds that improper payments have been made to you, they will submit claim adjustments to your MAC Helpful websites:
Comprehensive Error Rate Testing (CERT)
CERT Program developed by CMS to monitor and improve accuracy of Medicare claims for submission, processing and payment Claims are selected randomly Provider will be notified of overpayment or underpayment via remittance advice They are randomly selected by their system when a claim is submitted. The CERT call center hours are 8:00 AM to 6:00 PM EST, their phone number is (301) or
Zone Program Integrity Contractors (Medicare ZPIC Auditors)
ZPIC Pursuing providers with surprise on-site visits, targeted data analysis, random audits, 100% pre-payment holds, extrapolations and follow-up to whistleblower actions. In order to identify and challenge perceived Medicare fraud & abuse issues, ZPIC audits are based on a combination of claims data from multiple sources A sustained or high level of payment error may be determined to exist through a variety of means is not subject to administrative or judicial review
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