Additional Developmental Request (ADRs)/Appeals/LCDs

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CMS Quality Measurements Projects and the Goals

CMS is presently developing outcome core measures that are patient oriented and cross providers setting during the continuum of care.

Quality Management Role For The Betterment of Your Agency Picture

Quality Management Role For The Betterment of Your Agency

The Quality Manager can be a catalytic agent between departments in your organization. A Quality Manager in a strategic position in an organization can help improve revenues in multiple ways. Identifying processes assigned to staff ....

Encouraging Physicians to Properly Complete Face to Face Encounters

Physicians may find themselves being denied payment by CMS for Case Management overseen fees and office visits due to poor documentation in their patient\\\'s medical record.

Up-date to ICD-10!

Changes to ICD-10 for 2018-2019 from the CDC!


Patient-Driven Grouping Model (PDGM)-Effective January 1, 2020 CMS Home Health Payment Methodology. Picture

Patient-Driven Grouping Model (PDGM)-Effective January 1, 2020 CMS Home Health Payment Methodology.

Have you downloaded the CMS PDGM Excel file from the CMS Home Health Agency Center?

OASIS Tip - M1600 Patients discharged with an UTI on discharge and PAEs Report

Are your Potentially Avoidable Events (PAEs) Report showing an increase in patients being discharged while having an UTI?

Ready for CMS QAPI Program?

According to CMS in 2011 several nursing homes providers begun testing CMS QAPI Program, Quality Assurance (QA) and Performance Improvement (PI), Program which includes Five Elements...

ADRs and RACS in Medicare Home Health

The second round of F2F probe begun January 2017. Home health agencies who did not meet the F2F requirement in two or more of the five requested medical record will receive a request (ADRs)for five patient medical records.

Local Coverage Determination (LCDs)

All LCDs presently listed at the PalmettoGBA Home Health website were revised and are effective January 2017.

ADRs are unavoidable! Between automatic audits from MACs (Medicare Administrator Contractor) who performs current and prospective focus reviews and can impose severe administrative action as e.g. 100% prepayment review, RACs (A Recovery Audit Contractor) that performs retrospective focused reviews and corrects improper payment, CERTs (Comprehensive Error Rate Testing) program that reviews claims for proper Medicare coverage, ZPICs (Zone Program Integrity Contractor) that can place an agency on claims suspension for up to a year and a visit from the HEAT (Health Care Fraud Prevention and Enforcement Action Team)compose of DOJ/CMS/HHS Inspector General and more. When the H.E.A.T team contacts you or shows at your office or your home take it very seriously, they probably have been investigating you for a 1-2 years and they can and will close your business.

There are several processes an organization can put into place to reduce the risk of financial hardship:

1. Ensuring that your organization has a Corporate Compliance Officer who enforces your organization Corporate Compliance Program.

2. Includes corporate compliance education during orientation and annually.

3. Involving your Quality Management staff in the loop to perform audits on topics as how visit frequencies are establish, homebound status and medical necessity thru clinical chart audits and utilization review.

These and other measures may be able to decrease your risk of more audits and lost of revenue.

For example Home Health Care Network Today, Inc. have been able to achieved favorable outcomes from CMS audits in over 80% of ADRs and appeals by implementing similar interventions and:

The Medicare Overpayment Collection Process

According to CMS there are five levels in the Medicare Part A and Part B appeals process:

#1. Redetermination by a MAC

#2. Reconsideration by a Qualified Independent Contractor (QIC)

#3. Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals

#4. Review by the Medicare Appeals Council

#5. Judicial Review in Federal District Court

Last update: 3/9/2017

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