Medical Review Consulting

Critical Medical Review Assistance for Your Home Care or Hospice Agency

Home care and hospice industries are subject to multiple layers of review by government contractors. This is an ongoing process, and a critical need, where your agency may need guidance to prevent inaccurate results and a negative effect on your agency’s operations.

The HPS medical review consulting team can assist with reviewing charts that have been selected for Targeted Probe and Educate (TPE), Additional Development Request (ADR) reviews, Recovery Audit Contractor (RAC) reviews, Supplemental Medical Review Contractor (SMRC), Comprehensive Error Rate Testing (CERT) reviews and Unified Program Integrity Contractor (UPIC) reviews.

These reviews can impact the agency from a cash flow/revenue standpoint and will hold agencies to the documentation requirements of the Conditions of Participation and Conditions of Payment.

CMS has allowed post payment reviews to resume. As a result, the number of reviews being performed has increased immensely. HPS equips agencies to not only be successful at completing paperwork to submit for reviews, but to be successful at decreasing denial levels with education on improving documentation.

HPS medical review consulting provides guidance on every level of the appeals process, through and including ALJ appearances, if necessary.

Tips for Success

All three Medicare MACs and third party contractors can receive medical records for review by electronic submission. If your agency has not yet enrolled in the electronic submission of medical records, we recommend implementing that process as soon as possible. It is much easier to prove timely acceptance of the record when the record is submitted electronically to the MAC.

Both home care and hospice agencies should make sure that they have an organized process of checking for ADRs, including who has been assigned to clinically review the chart once it is assembled. Agencies really need to be successful in the first level of review and not be moved into a second round that could force 100% reviews.

1. Providers targeted for medical review have been receiving notification letters about the review and typically a list of patients and dates of service to be reviewed. Ensure that everyone knows where the letter needs to go for appropriate action.
2. Providers should ensure that medical records are submitted promptly upon request. Providers’ nonresponse to medical records requests will count as an error. This can trigger an automatic escalation of review of your agency and potentially a referral to one of the other contractors.
3. There should be a detailed clinical review of the chart prior to submission. Never just throw the chart together and send it on its way.

Recent Articles Written by Melinda A. Gaboury, COS-C