"Despite the COVID-19 public health emergency and the full resumption of the Medicare Review Choice Demonstration (RCD), medical review activities have been fully resumed. The triggering of a medical review poses an additional challenge to agency operations.
Aside from the RCD, multiple Medicare, Medicare Advantage, and commercial insurance reviewers examine medical records for accuracy, including those that are newly billed and reopened claims. It is common for home health agencies to focus on survey compliance rather than reviewing their medical records from a compliance and payment perspective. Medical reviews, audits, or probes can pose great difficulties if you are selected to undergo one of these processes.
Compliant clinical records are the key to success, whether it is through the RCD, the Unified Program Integrity Contractor (UPIC), the Recovery Audit Contractor (RAC), the Supplemental Medical Review Contractor (SMRC), or Comprehensive Error Rate Testing (CERT). The required rules and regulations should be incorporated into the content at the time of creation, not later.
The presentation begins by outlining key coverage requirements from Medicare regulations and what they actually require. It then provides examples of how to reflect these in the home health record to address known denial reasons. These include both nursing and therapy medical necessity requirements. In linking what is actually needed with known denial reasons, it shows how proper documentation can prevent negative outcomes. This also applies to the RCD when the full record is not reviewed in pre-claim review or when it is reviewed under an Additional Documentation Request (ADR) option.
This session provides a solid foundation for educating your staff to prevent future denials and audits. Your current staff can learn how to chart correctly, while new staff can learn from the actual regulations to start off right. The topics covered in this session can also be applied to Medicare Advantage medical reviews that are not subject to the RCD."
Understanding of the CMS, Medicare Advantage, and commercial payer medical review activity.
Knowledge of key CMS Medicare Benefit Policy Manual requirements.
A list of common denial reasons issued from Medicare and Medicare Advantage reviewers.
Knowledge of key items to be reviewed and staff education needed to successfully implement.
By completing/passing this course, you will attain the certificate HCAF Course Certificate
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