PYA Presents Intro to Healthcare Valuation PYA, P.C.
PYA Principal Jim Lloyd, along with other presenters, provided a “Healthcare Valuation 101” during a pre-conference workshop at the 2013 AICPA Healthcare Industry Conference.
PYA Presents Intro to Healthcare Valuation PYA, P.C.
PYA Principal Jim Lloyd, along with other presenters, provided a “Healthcare Valuation 101” during a pre-conference workshop at the 2013 AICPA Healthcare Industry Conference.
Are you afraid to encounter CMS & HHS RADV Audit risks? Stop worrying. Here is your guide to risk adjustment. Risk adjustment strategy revealed by subject Matter Experts Holly cassano and Kim Dues. You have got everything here. Data review to analysis , guidelines, formula, best practices and more. Come let's take a closer look https://goo.gl/fVQzet
Don’t Stumble Coming Out of the Gate –Top Ten Issues to Address When Acquirin...PYA, P.C.
PYA Consulting Principal Carol Carden co-presented with Charlene McGinty of McKenna Long. They examined the top issues to address when acquiring a physician practice and some of the common and more complex issues hospitals face during the acquisition.
Guarding Your Client's Valuation from Attack--Dos and Don'ts for Requesting, ...PYA, P.C.
During an AHLA webinar series roundtable discussion, “Guarding Your Client’s Valuation from Attack—Dos and Don’ts for Requesting, Reviewing, Using, and Discarding FMV Opinions,” PYA Principal Carol Carden joined other legal experts to explore the practical issues for counsel to consider when balancing the arguments for scrutinizing valuation reports with the arguments for ensuring valuator independence.
This presentation includes a detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The presentation provides an overview of the most recent MDS 3.0 User’s Manual updates and reviews key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.
Equity Transactions In The Ambulatory Surgical CenterJerrySokol
In today's market, there are a myriad of equity transactions taking place in the ambulatory surgical center (ASC) industry. These transactions typically fall into one of three categories. The first is the sale of ownership interests in an ASC to physicians who use or will be using the ASC. These transactions can involve the initial syndication of equity interests to physicians in a new ASC or the sale of equity interests to physicians in an existing ASC. Second is the redemption (i.e., buy-back) of a physician's equity interest in an ASC. Third is the sale of an equity interest to a corporate investor (e.g., ASC management companies and health systems).
Coordination of Benefits and its implications to Health PlansCitiusTech
Coordination of Benefits (COB) allows plans that provide health and/or prescription coverage with Medicare to determine their respective payment responsibilities (i.e. determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan). Member’s primary plan has the responsibility of paying claims first, followed by coverage by remaining plans. This process of splitting the costs across multiple coverage is called COB. This document introduces COB and how health plans and members benefit through COB regulations.
A detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The course will provide an overview of the most recent MDS 3.0 User’s Manual updates. The speaker will review key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.
Speaking before the Georgia Pediatric Practice Managers Association, PYA Consultant and ICD-10-CM Trainer Kim-Marie Walker addressed recent ICD-10 developments along with basic guidance for the transition, including:
• Comparison of ICD-9 and ICD-10
• ICD-10 organizational and structural differences
• Vendor recommendations and available resources
• Transition planning and roles
Critical issues in hospital and health system m&a fall 2014Rex James Burgdorfer
Since the enactment of the Affordable Care Act, the pace of hospital and health system consolidation has accelerated to a level not seen since the late 1990s, when hospitals were reacting to the formation of HMOs. The year 2013 saw a total of 87 consolidation transactions, following 105 in 2012. This volume represents a significant increase over 58, the median number of transactions completed each year between 2001 and 2011. Unlike the last wave of consolidation, which was driven primarily by financial and reimbursement considerations, today’s hospital mergers are just as likely to be between financially strong partners as they are to be in response to challenged operations or economics. Hospital companies increasingly are turning to mergers and acquisitions as a tool to improve quality, manage risk, access capital and contend with the changing regulatory environment. The articles in this collection explore the drivers of the current wave of consolidation, address the causes of transaction failures and review the range of structural alternatives available in the marketplace.
PYA Principal Jim Lloyd was among the faculty who spoke at the 2013 Mid-South Commercial Law Institute during a panel discussion on “Healthcare Facilities in Bankruptcy.” The presentation provided an overview of healthcare facilities and key issues, healthcare regulatory environment, valuation of healthcare facilities, and red flags for healthcare businesses in bankruptcy or distress.
PYA Healthcare Consulting Senior Manager Robert Mundy co-presented during, “Valuing Hospitals,” Thursday, July 31, at 1 p.m. EST. This webinar explores the changing world of hospital economics, regulations, and valuations and how appraisers can best prepare themselves for both the opportunities and challenges that lie ahead.
Are you afraid to encounter CMS & HHS RADV Audit risks? Stop worrying. Here is your guide to risk adjustment. Risk adjustment strategy revealed by subject Matter Experts Holly cassano and Kim Dues. You have got everything here. Data review to analysis , guidelines, formula, best practices and more. Come let's take a closer look https://goo.gl/fVQzet
Don’t Stumble Coming Out of the Gate –Top Ten Issues to Address When Acquirin...PYA, P.C.
PYA Consulting Principal Carol Carden co-presented with Charlene McGinty of McKenna Long. They examined the top issues to address when acquiring a physician practice and some of the common and more complex issues hospitals face during the acquisition.
Guarding Your Client's Valuation from Attack--Dos and Don'ts for Requesting, ...PYA, P.C.
During an AHLA webinar series roundtable discussion, “Guarding Your Client’s Valuation from Attack—Dos and Don’ts for Requesting, Reviewing, Using, and Discarding FMV Opinions,” PYA Principal Carol Carden joined other legal experts to explore the practical issues for counsel to consider when balancing the arguments for scrutinizing valuation reports with the arguments for ensuring valuator independence.
This presentation includes a detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The presentation provides an overview of the most recent MDS 3.0 User’s Manual updates and reviews key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.
Equity Transactions In The Ambulatory Surgical CenterJerrySokol
In today's market, there are a myriad of equity transactions taking place in the ambulatory surgical center (ASC) industry. These transactions typically fall into one of three categories. The first is the sale of ownership interests in an ASC to physicians who use or will be using the ASC. These transactions can involve the initial syndication of equity interests to physicians in a new ASC or the sale of equity interests to physicians in an existing ASC. Second is the redemption (i.e., buy-back) of a physician's equity interest in an ASC. Third is the sale of an equity interest to a corporate investor (e.g., ASC management companies and health systems).
Coordination of Benefits and its implications to Health PlansCitiusTech
Coordination of Benefits (COB) allows plans that provide health and/or prescription coverage with Medicare to determine their respective payment responsibilities (i.e. determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan). Member’s primary plan has the responsibility of paying claims first, followed by coverage by remaining plans. This process of splitting the costs across multiple coverage is called COB. This document introduces COB and how health plans and members benefit through COB regulations.
A detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The course will provide an overview of the most recent MDS 3.0 User’s Manual updates. The speaker will review key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.
Speaking before the Georgia Pediatric Practice Managers Association, PYA Consultant and ICD-10-CM Trainer Kim-Marie Walker addressed recent ICD-10 developments along with basic guidance for the transition, including:
• Comparison of ICD-9 and ICD-10
• ICD-10 organizational and structural differences
• Vendor recommendations and available resources
• Transition planning and roles
Critical issues in hospital and health system m&a fall 2014Rex James Burgdorfer
Since the enactment of the Affordable Care Act, the pace of hospital and health system consolidation has accelerated to a level not seen since the late 1990s, when hospitals were reacting to the formation of HMOs. The year 2013 saw a total of 87 consolidation transactions, following 105 in 2012. This volume represents a significant increase over 58, the median number of transactions completed each year between 2001 and 2011. Unlike the last wave of consolidation, which was driven primarily by financial and reimbursement considerations, today’s hospital mergers are just as likely to be between financially strong partners as they are to be in response to challenged operations or economics. Hospital companies increasingly are turning to mergers and acquisitions as a tool to improve quality, manage risk, access capital and contend with the changing regulatory environment. The articles in this collection explore the drivers of the current wave of consolidation, address the causes of transaction failures and review the range of structural alternatives available in the marketplace.
PYA Principal Jim Lloyd was among the faculty who spoke at the 2013 Mid-South Commercial Law Institute during a panel discussion on “Healthcare Facilities in Bankruptcy.” The presentation provided an overview of healthcare facilities and key issues, healthcare regulatory environment, valuation of healthcare facilities, and red flags for healthcare businesses in bankruptcy or distress.
PYA Healthcare Consulting Senior Manager Robert Mundy co-presented during, “Valuing Hospitals,” Thursday, July 31, at 1 p.m. EST. This webinar explores the changing world of hospital economics, regulations, and valuations and how appraisers can best prepare themselves for both the opportunities and challenges that lie ahead.
DocSend Fundraising Research: What we Learned from 200 Startups Who Raised $360MDocSend
Why do some startups get funded? What makes for the best pitch? How does the process work?
DocSend recently teamed up with Professor Tom Eisenmann from Harvard Business School. Together, we conducted research that gave us the answers to those questions. We studied the fundraising of 200 startup companies as they went through their Series Seed and Series A rounds. Altogether, these companies raised more than $360 million.
Why this data is awesome:
Fundraising is a historically opaque endeavor. There’s very little data available and most advice tends to be anecdotal. DocSend is in the unique position of being able to quantitatively analyze the interaction between founders and investors, and tie that to fundraising outcomes in a statistically meaningful way.
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DocSend aims to help companies share documents in a smarter, safer, and more impactful way. We believe this research is in service of that mission and can help push the startup ecosystem forward as a whole.
Background on DocSend:
DocSend helps sales people track and control documents they send to clients. We’ve also become very popular amongst founders in the fundraising process. Hundreds of startups have used our platform to circulate pitch decks to investors.
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How to Become a Thought Leader in Your NicheLeslie Samuel
Are bloggers thought leaders? Here are some tips on how you can become one. Provide great value, put awesome content out there on a regular basis, and help others.
How to Make Awesome SlideShares: Tips & TricksSlideShare
Turbocharge your online presence with SlideShare. We provide the best tips and tricks for succeeding on SlideShare. Get ideas for what to upload, tips for designing your deck and more.
A white paper written for Bluepoint Solutions that discusses the context for enterprise content management. Regulatory compliance demands have grown in recent years as a result of Dodd-Frank regulations rendering the old IT systems obsolete.
SR&ED funds can go direct to Investigators and does not interfere with other fund sources or have ethics issues.
We have crafted strategies to maximize the dollars realized,minimize the effort of assembling claims and avoid unnecessary CRA headaches. Clients care about their after-tax position, as well as cash flow, retirement needs and estate planning. Annual SR&ED rebates can be significant, but need to harmonize with other strategies to give the greatest benefit. Goulet Associates strives to supply one piece of the larger puzzle.
Medical groups and individual practices in Georgia that struggle managing denials or write off denied claims as bad debts can now handle denial with the help of these strategies.
Learn how to be a RAC Survivor with Laura Legg, HRG Executive Director of Revenue Integrity and Compliance, in this thirty-three slide presentation. Get updated on the 2017 RAC Audit changes and what you can do to prevent a RAC attack.
For more info visit: http://www.hrgpros.com/rac-audit-optimization
hrgpros.com
@hrgpros
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There are three main strategies for billing: becoming credentialed as a provider, obtaining preauthorization before submission, and submitting the claim without prior authorization. If a pharmacist is credentialed with the insurance carrier, he or she is already authorized to submit claims to the insurance company for those patients using the pharmacist’s program.
The Centers for Medicare and Medicaid Services (CMS) has long published a list of procedures that—for safety reasons—providers could only perform and receive reimbursement for in the hospital inpatient setting (the Inpatient-Only (IPO) list). However, in 2020, CMS announced a plan to phaseout the IPO list, which would have removed the inpatient requirement for certain services. More recently, a CMS ruling reversed the 2020 phaseout, thereby reinstating the IPO list. Many stakeholders consider the reversal of the phaseout a benefit to patients, providers, and hospitals in terms of improved patient safety, increased reimbursement, reduced physician burden, and more.
US Medical Billing A Comprehensive Overview for Healthcare Providers.pdfmedquikhelathsolutio
The intricate world of medical billing can feel like a labyrinth for healthcare providers. Between deciphering complex medical codes, navigating insurance regulations, and ensuring timely reimbursements, it's easy to get overwhelmed.
Capitalizing on the ICD-10 Coding System: What Healthcare Organizations Need ...Cognizant
Having transitioned successfully to the ICD-10 coding system, healthcare organizations must now look beyond simply achieving compliance, and employ the system to identify and eliminate financial divergence, reduce revenue leaks, improve quality ratings, and drive competitive advantage.
Why Revenue Cycle Management Matters For RCM Healthcare Providers.pptMatthew Clark
The healthcare landscape in the United States is undergoing the significant changes, driven by factors such as evolving regulations, increasing patient expectations, and advances in medical technology. In this dynamic environment, healthcare providers are constantly striving to deliver high-quality patient care while maintaining financial stability. One crucial aspect that plays a pivotal role in achieving this delicate balance is revenue cycle management (RCM).
1. Welcome
to
a
“Medical
Billing
Errors
&
Omissions:
Exposures
and
Solu;ons”.
My
name
is
Sco?
Fikes,
Vice
President
of
Physician
Services
for
InLight
Risk
Management,
a
specialty
insurance
firm
exclusively
serving
the
healthcare
industry.
During
this
Webinar,
we
will
review
Who
RAC
is,
its
objec;ves
and
solu;ons
designed
to
protect
your
healthcare
organiza;on
from
the
unexpected
financial
loss
of
a
government
or
commercial
payor
audit.
1
2. In
the
Tax
Relief
and
Health
Care
Act
of
2006,
Congress
required
a
permanent
and
na;onal
RAC
program
to
be
in
place
by
January
1,
2010.
The
na;onal
RAC
program
is
the
outgrowth
of
a
successful
demonstra;on
program
that
used
RACs
to
iden;fy
Medicare
overpayments
and
underpayments
to
health
care
providers
and
supplier.
RAC
is
the
acronym
for
Recovery
Audit
Contractors.
2
3. The
demonstra;on
was
limited
to
only
a
few
select
states
mostly
located
in
the
west
and
east
coast.
The
demonstra;on
resulted
in
over
$900
million
in
overpayments
being
returned
to
the
Medicare
Trust
Fund
between
2005
and
2008
and
nearly
$38
million
in
underpayments
returned
to
health
care
providers.
3
4. The
goal
of
the
recovery
audit
program
is
to
iden;fy
improper
payments
made
on
claims
of
health
care
services
provided
to
Medicare
beneficiaries.
Improper
payments
may
be
overpayments
or
underpayments.
Overpayments
can
occur
when
health
care
providers
submit
claims
that
do
not
meet
Medicare’s
coding
or
medical
necessity
policies.
Underpayments
can
occur
when
health
care
providers
submit
claims
for
a
simple
procedure
but
the
medical
record
reveals
that
a
more
complicated
procedure
was
actually
performed.
4
6. This
illustra;on
provides
the
proposed
jurisdic;ons.
Focusing
on
jurisdic;on
“C”,
Oklahoma,
Texas,,
Florida,
New
Mexico
and
Colorado
will
begin
March
2009
with
the
remaining
states
to
follow
in
August
2009
or
later.
6
8. Medicare
delayed
the
contract
award
due
to
a
dispute
in
the
bidding
process
by
two
unsuccessful
bidders
for
the
RAC
program.
Under
the
GAO
(General
Accoun;ng
Office),
a
deadline
of
100
days
was
given
to
make
a
determina;on.
8
9. On
February
4,
2009
the
par;es
involved
in
the
protest
of
the
award
of
the
Recovery
Audit
Contractor
(RAC)
contracts
se?led
the
protests.
The
se?lement
means
that
the
stop
work
order
has
been
liied
and
CMS
will
now
con;nue
with
the
implementa;on
of
the
RAC
program.
9
10. In
jurisdic;on
“C”,
Connolly
Consul;ng,
Inc.
received
the
RAC
award.
All
correspondence,
websites
and
call
centers
will
be
in
the
name
of
the
RAC’s.
10
11. Connelly
Consul;ng
Associates,
Inc.
is
located
in
Wilton,
Connec;cut.
About
Connolly
Healthcare
Connolly
Healthcare,
a
division
of
Connolly
Consul;ng,
is
the
recovery
audit
expert
that
uses
advanced
data
mining
techniques
to
iden;fy
and
recover
a
broad
range
of
erroneous
medical
claim
payments,
all
with
a
high
sensi;vity
to
important
provider
rela;onships.
In
2007,
Connolly
reviewed
more
than
$150
billion
dollars
in
paid
medical
claims
working
with
some
of
the
largest
health
plans
in
the
United
States.
Recovery
audi;ng
is
recognized
as
a
best
prac;ce
and
Connolly's
exper;se
places
it
in
a
posi;on
to
propose
vital
process
improvement
recommenda;ons
to
reduce
or
eliminate
future
improper
payments.
Informa;on
on
Connolly
Healthcare
and
its
services
can
be
obtained
at:
www.connollyhealthcare.com
or
by
contac;ng
Connolly's
Press
Release
Contact:
PRContact@connollyhealthcare.com
SOURCE
Connolly
Healthcare
William
Pisani,
+1-‐203-‐529-‐2000,
of
Connolly
Healthcare
11
13. 1. Is
RAC
a
new
issue
facing
the
healthcare
industry?
No.
Medical
facili;es
have
had
RAC-‐related
issues
since
the
1980s.
2.
What
were
the
biggest
challenges
confron;ng
medical
facilitates
par;cipa;ng
in
the
3-‐year
RAC
demonstra;on
program?
Managing
data
such
as
the
number
of
requests
coming
in
and
the
paperwork
going
out
of
the
facility.
Another
challenge
was
managing
the
review
process
and
remi?ances,
which
included
keeping
track
of
monetary
flows
and
differen;a;ng
RAC
requests
from
other
requests.
It
is
important
to
be
prepared
from
a
ROI
standpoint.
You
must
make
sure
you
have
adequate
staff
to
handle
requests
and
be
able
to
handle
DRG
coding
issues,
which
may
lead
to
RAC
denials
which
is
a
result
of
uneducated
staff.
Tracking
RAC
ac;vi;es
is
also
cri;cal.
Medical
facili;es
started
out
tracking
data
on
Excel
spreadsheets
but
later
had
to
move
the
informa;on
to
a
database
because
of
the
large
amounts
of
informa;on.
3.
What
was
the
biggest
obstacle
that
confronted
RAC
providers
during
the
demonstra;on
program?
Last
minute
requests
from
par;cipa;ng
medical
facili;es
asking
for
extensions
on
delivering
RAC
medical
requests.
4. What
was
the
most
difficult
area
to
target
for
par;cipa;ng
medical
facili;es?
Separa;ng
simple
versus
complex
pneumonia
cases,
sepsis
versus
neuro-‐
sepsis,
CHS,
wound
debridements,
chest
pains,
syncope,,
medical
necessity,
and
denial
of
inpa;ent
rehab
encounters
were
all
difficult.
13
14. 5.
Does
CMS
offer
documenta;on
that
pinpoints
what
caused
the
worst
RAC
issues
for
organiza;ons
par;cipa;ng
in
the
demonstra;on
program?
Yes.
CMS
offers
two
reports
posted
on
their
web
site
outlining
the
various
issues
encountered,
including
challenges
with
coding,
medical
necessity,
etc.
To
see
these
reports,
go
to
h?p://www.cms.hhs.gov/rac.
6. Was
the
RAC
demonstra;on
ini;a;ve
random?
No.
The
CMS
was
not
commissioned
to
use
a
random
approach.
RACs
are
not
only
looking
at
DRGs
but
are
also
reviewing
ICD9
diagnosis
codes,
charges,
and
length
of
stays
for
inpa;ents.
A
DRG
payment
that
is
significantly
higher
than
the
charges
is
a
red
flag
to
RAC
and
will
probably
be
inves;gated.
7. On
average,
how
may
RAC
reviews
uncover
an
improper
payment
finding?
Three
out
of
10
reviews
reveal
an
improper
payment.
HealthPort
::
RAC
Preparedness
8. How
important
is
day-‐to-‐day
coding
when
it
comes
to
the
RAC
demonstra;on?
Very
important.
RAC’s
methodology
is
based
on
ICD9
and
CPT4
coded
data
because
payment
is
based
on
coding.
RAC
will
easily
recognize
a
sepsis
that
is
a
two-‐day
stay
and
a
secondary
UTI
diagnosis.
14
15. 9. Did
facili;es
par;cipa;ng
in
the
RAC
demonstra;on
follow
CMS’s
instruc;ons
on
extrapola;on
methodology
for
internal
findings?
No.
None
of
the
par;cipa;ng
facili;es
did
extrapola;on.
For
extrapola;on
a
provider
must
have
a
high
level
of
error
that
can
be
demonstrated
by
a
sta;s;cian
and
other
similar
professionals.
For
more
details
on
extrapola;on,
go
to
www.cms.hhs.gov/manuals.
10. Will
extrapola;on
eliminate
the
RAC
process
for
organiza;ons?
No,
because
it
is
targeted
to
limited
areas.
HealthPort
::
RAC
Preparedness
::
RAC
FAQs
h?p://
www.healthport.com/RAC_FAQs.aspx
11. Did
RAC
focus
on
one
type
of
medical
facility
over
another
(i.e.
profit
or
not-‐for-‐
profit,
teaching
or
non-‐teaching
hospital,
urban
or
suburban
facility,
acute
care
or
long-‐term
cri;cal
access?
No.
They
included
all
types
of
medical
facili;es.
15
16. 12. Were
states
that
had
less
CMS
beneficiaries
reviewed
differently?
A
final
decision
has
not
been
made
on
the
limita;on
cap.
During
the
RAC
demonstra;on,
PRG
Connolly
based
medical
record
limits
on
the
number
of
monthly
chart
requests;
however,
HDI
thought
it
was
fairer
to
base
it
on
Medicare
revenue
per
provider.
13. Whom
should
a
medical
facility
appoint
as
gatekeeper
for
the
RAC
process?
While
it
is
each
facility’s
decision,
based
on
its
par;cular
needs,
an
onslaught
of
coding
and
reimbursement
issues
would
necessitate
that
the
Health
Informa;on
Management
(HIM)
department
should
be
gatekeeper.
HIM
also
holds
the
records.
However,
if
the
biggest
area
of
risk
is
medical
necessity,
than
Case
Management
or
Pa;ent
Financial
Services
may
want
to
handle
this
responsibility.
A
facility
may
also
develop
a
task
force
that
includes
Corporate
Compliance,
Revenue,
and
the
Central
Business
Office,
with
HIM
heading
up
the
task
force.
14. Will
RAC
use
cer;fied
coders
and
medical
directors
in
the
na;onal
program?
Yes.
RAC’s
statement
of
work
requires
hiring
only
cer;fied
coders.
During
the
early
por;on
of
the
RAC
demonstra;on,
some
non-‐cer;fied
coders
were
ini;ally
used.
However
going
forward,
RAC
has
s;pulated
that
only
cer;fied
coders
should
be
used.
Likewise,
in
the
na;onal
program,
the
four
RACs
will
be
required
to
use
medical
directors,
as
well.
15. When
will
CMS
start
distribu;ng
the
RAC
le?ers?
It
is
an;cipated
that
the
RAC
le?ers
will
begin
going
out
in
April
or
May
2009.
HealthPort
::
RAC
Preparedness
::
RAC
FAQs
h?p://
www.healthport.com/RAC_FAQs.aspx
16
17. Selected
under
a
full
and
open
compe;;on.
The
RACs
will
be
paid
on
a
con;ngency
fee
basis
on
both
the
overpayments
and
underpayments
they
find.
The
selec;on
was
based
on
a
best
value
determina;on
for
the
Federal
government
that
included
a
sound
technical
approach
for
the
level
and
quality
of
claim
analysis
and
detail
to
excep;onal
customer
service,
conflict
of
interest
reviews
and
lowest
con;ngency
fee.
17
18. Medicare
RAC
Appeals
/
Denials
/
Overpayment
Determina7on
The
following
informa;on
MUST
be
included
with
your
request
for
all
appeal
levels:
Beneficiary
name
Medicare
Health
Insurance
Claim
(HIC)
Number
Specific
service(s)
and/or
item(s)
for
which
the
redetermina;on
/
reconsidera;on
is
being
requested
Specific
date(s)
of
the
service;
and
Name
and
signature
of
the
provider
or
the
representa;ve
of
the
provider
First
Level
–
Redetermina7on
(Medicare
Administra7ve
Contractor)
Claim
denials
or
overpayments
must
be
ini;ally
reviewed
(appealed)
to
the
appropriate
Medicare
Administra;ve
Contractor
(MAC)
by
reques;ng
a
redetermina;on
of
the
claim
within
120
days
of
the
RACs
ini;al
decision.
Medicare
Administra;ve
Contractors
are
required
to
respond
to
a
provider’s
request
for
redetermina;on
within
60
days
of
receipt.
Second
Level
–
Reconsidera7on
(Qualified
Independent
Contractor)
If
a
provider
is
dissa;sfied
with
the
outcome
of
the
Level
1
appeal
or
redetermina;on
process,
a
request
for
“reconsidera;on”
may
be
filed
with
the
appropriate
Qualified
Independent
Contractor
(QIC)
within
180
days
of
the
redetermina;on.
Requests
for
reconsidera;on
are
required
to
be
processed
within
60
days
by
the
QIC.
Third
Level
–
Administra7ve
Law
Judge
Hearing
If
a
provider
is
not
sa;sfied
with
Level
2
and
the
result
of
reconsidera;on,
a
hearing
before
an
Administra;ve
Law
Judge
(ALJ)
can
be
requested.
The
amount
in
controversy
must
be
a
minimum
of
$120
and
requests
for
a
hearing
from
an
ALJ
must
be
received
within
60
days
of
the
provider’s
no;ce
of
the
reconsidera;on
outcome.
Fourth
Level
–
Medicare
Appeals
Council
(MAC)
If
the
Level
3
appeal
and
decision
by
the
ALJ
is
considered
unfavorable
by
the
provider,
a
fourth
level
appeal
request
may
be
filed
with
the
Departmental
Appeals
Board
(DAB)
/
Medicare
Appeals
Council
(MAC).
Requests
for
a
MAC
review
must
be
filed
within
60
days
of
receipt
of
the
ALJ’s
decision.
The
MAC
must
subsequently
issue
a
determina;on
within
90
days
of
the
review.
FiIh
Level
–
U.S.
District
Court
Review
If
the
Level
4
decision
of
the
MAC
is
deemed
unfavorable
to
the
provider,
the
final
step
in
the
appeals
process
is
to
file
suit
in
U.S.
District
Court.
Requests
must
be
filed
within
60
days
of
the
MACs
decision
and
the
amount
in
controversy
must
be
at
least
$1,180.
18