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Welcome to Focused Medical Review ADR s brought to you by:

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Welcome to Focused Medical Review ADR s brought to you by:

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    1. Welcome to Focused Medical Review & ADRs brought to you by:

    2. Focused Medical Review & ADR's Michael McGowan MBA/HCA Senior Consultant michael@madappeals.com www.madappeals.com 916-343-1164

    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 ICD-9 coding Patient acuity vs. service utilization Previous provider services

    6. Documentation deficiencies Medical necessity what is it really? Homebound Status 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

    10. Questions? Visit us at www.madappeals.com Email for a free chart audit tool michael@madappeals.com

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