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Medical Necessity Services

As the number and complexity of governmental healthcare regulations continues to escalate, it is easy for healthcare providers to get left behind. CBIZ can help providers avoid denials and suspended claims by assessing the potential compliance risks and designing proactive plans to avoid future denials.

Engagements include:

Medicare Compliance & Denial Management

We provide a wide portfolio of services aimed at improving your facility’s compliance with Medicare statutes and, ultimately, increasing your reimbursement. All of CBIZ's denial management services are staffed by nurses with Medicare fiscal intermediary experience and a first-hand understanding of hospital operations. Services offered by CBIZ include:

Additional Development Request Management. CBIZ will analyze and coordinate Medicare intermediary and carrier record requests, review chart documentation and stop the unending cycle of focused medical review. Our team:

  • Analyzes record requests and develop a revenue protection plan
  • Reviews suspended or denied ADR accounts to identify medical necessity and completeness of the medical record
  • Contacts the referring physician office or hospital department to receive additional case history or paperwork when necessary
  • Copies, organizes and reviews chart components for compliance with Medicare guidelines
  • Provides feedback on documentation issues and recommend corrective actions
  • Tracks ADR payment outcomes

Medicare Appeal Management. CBIZ will review claim rejections and denials and initiate claim resubmissions or appeals to the fiscal agent for cases where a high likelihood of payment is predicted. Our team:

  • Reviews Medicare vouchers to identify Medicare denials and provider appeal rights
  • Copies medical records needed for appeal submission
  • Completes Medicare appeal forms and case development for accounts identified by CBIZ as having a high likelihood of payment
  • Submits the appeal package to the Medicare intermediary and carrier
  • Tracks Medicare appeal outcomes

Denial Management Services for Medicare, Medicaid and Managed Care Payers. CBIZ provides a full array of denial management services that create long-term process changes and result in reduced denials and improved reimbursement. CBIZ's denial services analyze the entire cycle of patient billing, including front-end processes such as patient enrollment, eligibility, coordination of benefits and classification, and back-end management, including the appeals process. Our team:

  • Ensures that appropriate Medicare guidelines regarding pre-admission documentation are followed, including advanced beneficiary notification (ABN) and medical necessity guidelines
  • Evaluates local coverage determinations (LCDs) and develops procedures to avoid denials
  • Creates process improvement initiatives to ensure the correct classification of inpatient versus same day surgery versus observation
  • Establishes an eligibility process improvement initiative to capture re-admissions and correct personal identifiers (e.g. Medicaid numbers and Social Security numbers)
  • Reviews all documentation in the hospital record or referring physician’s file to substantiate medical necessity
  • Analyzes and creates streamlined Medicare appeals and resubmission processes
  • Facilitates claim adjudication by utilizing CBIZ's experience in collaborating with state agencies
  • Develops necessary contractual language in all managed care contracts
  • Audit payments from Managed Care Organizations to determine if correct reimbursement was received

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Medicare Focused Medical Review Services

Focused medical review is a pre-payment utilization review process implemented by Medicare fiscal intermediaries to assess outpatient coverage and billing compliance with Medicare reimbursement regulations. Fiscal intermediaries are not required to notify hospitals regarding the initiation of focused medical review. Hospital administration may not be aware of the process until the scope of the review encompasses multiple outpatient departments and a dramatic impact on cash flow is evident. Once a hospital is on focused medical review, the fiscal intermediary requires that specific criteria be met before they will release hospital outpatient services from pre-payment claim suspension.

CBIZ helps providers to navigate the focused medical review process by meeting the specific criteria needed to be released from the review. Our team also helps by developing corrective plans to avoid future reviews. CBIZ gathers all focused medical review documents requested by the fiscal intermediary and guarantees timely submission. We educate providers regarding how to avoid future reviews through the analysis of denied claims and development of a corrective action plan. In addition to improving revenue, this service also protects providers from Medicare fraud and abuse investigations and OIG audits.

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Compliance Education

Physician Education. CBIZ offers a variety of education programs aimed at providing physicians with vital and timely information regarding Medicare guidelines. Through CBIZ's seminars, providers learn how to prevent cash flow delays and prepare patients for what to expect during their care process. Listed below are just some of the educational programs available:

  • Understanding Medicare Edits and Local Coverage Determinations
  • Medicare Denial Management: Shifting office strategies to improve cash flow
  • Understanding Medicare Advance Beneficiary Notifications (ABN’s)
  • Medicare Home Health Benefits
  • Medicare Compliance Hot Topic: Hospital admissions and one-day stays
  • Writing Orders for Medicare Patients: Trends in diagnosis coding

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Stacy Pereira Stacy Pereira Executive Director
Rachel A. Lawrence Rachel A. Lawrence Senior Manager