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Home HealthMedicare Audits
June 27, 2013
F.O.R.C.E. Healthcare Resources, LLC(Founded on Regulatory Compliance and Ethics)
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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
Contact InformationF.O.R.C.E Healthcare Resource, LLC.
– Website: www.forcehealthcare.com• Terri Ready, COO
- Direct: 423-643-2256 ext. 104- Mobile: 423-593-1627- [email protected]
• Lynn Alley, Office Manager– Direct: 423-643-2256 ext. 107– [email protected]
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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:
http://www.cms.hhs.gov/OrgMedFFSAppeals/Downloads/AppealsprocessflowchartAB.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: http://cmsaudits.com/CMS_Questions___Answers.html
http://www.aaos.org/govern/federal/Medicare/Medicare_Audits_101.asp
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) 957-2380 or 1-888-779-7477.
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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