Medicare and Medicaid Clinical Compliance Management
Concurrent Admission Review and Certification

EHR Physician Advisor teams, trained in Medicare and Medicaid rules and regulations pertaining to observation and inpatient status, provide the required secondary, concurrent physician review of Medicare/Medicaid observation status cases and inpatient admissions that do not meet case management’s medical necessity screening criteria. The EHR admission review applies evidence-based medicine, CMS guidance, and EHR’s unique database of hundreds of thousands of validated physician advisor reviews to ensure appropriate admission status certification, complete chart documentation, the highest level of compliance with CMS rules, and revenue integrity.

EHR also leverages proprietary, evidence-based, risk stratification protocols and algorithms to assist its Physician Advisors in determining the appropriate admission status. The result is a Physician Advisor second-level review that provides an admission status certification supported by clinical evidence, compliant with CMS rules and regulations, and robust enough to withstand external scrutiny.

EHR has been at the forefront of the complex issue of determining short stay admission versus observation status, having audited thousands of charts across the U.S. as part of its hospital evaluation process for Medicare clinical compliance. EHR’s audit findings include:

1. An average 35-50% improper application of observation status (revenue loss/compliance risk)
2. An average 20-40% improper application of inpatient status (compliance risk)

EHR’s concurrent admission review and certification solution eliminates this variance and ensures compliance with CMS claim status certification rules and regulations.

Medicare and Medicaid Procedural Setting Review and Compliance Management
Interventional Cardiac Procedures

EHR has created sophisticated, clinical evidence-based, risk stratification protocols and algorithms for use by its teams of expert Physician Advisors to assist in accurately determining admission claim status for procedures.

Interventional Cardiac Procedures (ICPs), including Implantable Defibrillators, Pacemakers, Cardiac Stents, and Angioplasties, are no longer on the Medicare inpatient only list of procedures, and have been largely eliminated from other commercial lists as well. As a result, hospitals often routinely err by assigning outpatient status to these procedures.  The paradigm of assigning claim status based solely on the procedure itself is no longer valid.

EHR’s Physician Advisor reviews provide a risk-stratified, evidence-based claim status certification supported by published evidence and compliant with CMS rules and regulation and federal law. 

Medicare and Medicaid Denials Review & Appeal Management
Retrospective Review and QIO, MAC/FI and RAC Appeals Management

In addition to managing denials and audits from Quality Improvement Organizations (QIO), Medicare Administrative Contractors (MAC) and Fiscal Intermediaries (FI), hospitals are now faced with the challenge of how to defend, repay, or self disclose past issues that may be identified in the expanding Recovery Audit Contractor (RAC) program. RACs collected nearly $700 million dollars of improper Medicare payments between 2005 and March 2008, according to the June 2008 Medicare RAC Program Evaluation Report. More than 96% of the improper payments were overpayments collected from providers and only 4% were underpayments.

The denial appeals process is lengthy, complicated and requires expertise in both medical necessity and Medicare regulations. Many cases result in Administrative Law Judge (ALJ) appeals, often requiring participation in administrative hearings and the creation of detailed supporting memoranda.

EHR Physician Advisors are experts in managing the QIO and FI Reconsideration, Administrative Law Judge (ALJ) hearing and Departmental Appeals Board (DAB) and RAC appeal processes. EHR has managed and successfully appealed RAC denials in demonstration project states. Our team has amassed extensive experience with all stages of the RAC review and appeal process and achieved unmatched success in obtaining the reversal of thousands of admissions inappropriately denied by RACs.

EHR appeals QIO, FI and RAC denials based upon medical necessity, payment rules and points of law. EHR’s in-depth understanding of the Code of Federal Regulation results in superior appeal outcomes and allows for a coordinated process with its clients’ case management, compliance, and legal departments. Additionally, EHR’s concurrent Physician Advisor services provide hospitals with a strong RAC denial prevention solution through real-time medical necessity review, maintaining regulatory compliance and limiting a hospital’s exposure risk going forward.