1. Welcome to Focused Medical Review & ADR’s brought to you by:
2. Focused Medical Review & ADR's Michael McGowan MBA/HCA
[email protected] www.madappeals.com
3. Why the increase in activity nationwide? Demonstration projects are over
RHHI's who owns them really?
Parent companies ranging from WellPoint to Blue Cross Blue Shield
RHHI's under Corrective action from CMS
US Attorney General, DOJ, FBI, OIG, ZPIC, HEAT, PSC's
Where are the RAC's?
4. Why your agency will be probed during the next 18 months… MLR rate has risen 50% in FY 2009
Aetna demonstrated a 1.4% MLR in 90 days and...
DME and Home Health are the two highest risk areas.
The Da Vinci syndrome
What is waste and abuse?
5. Data Triggers first… Charts second… Initial vs. second or third episodes
Initial case mix weight
Final case mix weight
Spread between initial and final
Patient acuity vs. service utilization
Previous provider services
6. Documentation deficiencies Medical necessity what is it really?
Nondescript charting/Cloned charting
Teaching patients and caregivers, often the weakest service
Timeliness in charting and accuracy
Physical therapy evaluations, re-assessments, thresholds
Nursing HPI and OAISIS
7. The Probe Edit Process… The list is selected by the computer
Selection of 40 or so charts from the RHHI
Analysis by medical review staff.
Mostly Nurses, and a few Therapists.
Passing score 15% error in billing or less.
Over 150 charts often reviewed
Did your chart audit tools prepare you?
8. Focused medical review processes
15-20% Error rate
40-55% Error rate
When focused medical review begins immediately
Targeted medical review 12-18 months
Three to four 90 day sessions on review
Writing a plan of corrective action to the RHHI
9. Referral to Program Safeguard Teams.
The benefit integrity group
Actions during audit
Triggers to referrals
Visit us at
Email for a free chart audit tool