Lifecare’s core competencies include legal counsel, accounting, auditing, assessments and reviews, investigations, data analysis, data mining, case management, clinical coding, clinical auditing and training, and centralized operations center management. Lifecare’s principal owner, Joseph C. Molina, LLM, JD has extensive experience in law, Medicare regulations, transitions of Medicare operations to new contractors, CMS payment error rate initiatives, background investigations, joint operating agreements, Medicare documentation requirements, medical reviews and overpayment recoveries involving statistically valid random samples, law enforcement fraud referrals, and pro-active data analysis of large data sets and complex data sets. As the Utilization Management and Benefit Integrity Manager (UMBI) Mr. Molina headed the transition of all Medicare benefit integrity, post pay medical review and data analysis functions from Nationwide Insurance Medicare Part B, Ohio and West Virginia, to AdvanceMed, the PSC contractor. He served as the Medicare Chief Legal Counsel for the Ohio (Part A and B) and West Virginia (Part B) Medicare Program Safeguard Contractor task order. He also served as Chief Legal Counsel in five other states. He provides guidance across all Lifecare contracts requiring legal, accounting and investigative services.
Lifecare is currently one of the 12 companies originally selected by Centers for Medicare and Medicaid Services (CMS) as a Medicare Program Safeguard Contractor (PSC) under its anti-fraud and abuse initiative, and serves as a principal subcontractor to one other PSC contractor. As prime contractor, Lifecare was awarded a CMS task order to support CMS and the Office of Inspector General’s review of nebulizer drug payments in 17 states. Phase 1 of the task order required creating a comprehensive database; receiving and reviewing medical record source documents, notes from beneficiary interviews, and commentaries from medical providers; analyzing findings; and calculate a payment error rate based upon the findings. Phase 2 involved a focused review of the top dollar durable medical equipment (DME) suppliers in three states. In Texas, Lifecare conducted all beneficiary, provider, and DME supplier interviews and collected all other applicable data including the medical records, and then accumulated data from two additional states where the OIG and CMS conducted the same processes, populated a consolidated database of findings, analyzed the results, and calculated another payment error rate. The OIG issued an extensive report identifying the problems and dollars associated with each area of concern, and both OIG and CMS publicly acknowledged the work contributed by Lifecare to the effort. Based on the medical and document review by Lifecare, the OIG estimated that 60% of the $224 million in payments made by the Region C DMERC for inhalation drugs was either unallowable or not sufficiently documented to determine their allowability in accordance with Medicare requirements. Other outcomes of the effort resulted in Lifecare generating 10 fraud alerts based on the medical reviews, public record searches and interviews and developing a comprehensive lessons learned report.
As a subcontractor on four PSC contracts to AdvanceMed Corporation, Lifecare has staffed Chief Legal Counsel, Senior Fraud Investigator, Senior Data Analyst, and Utilization Management and Benefit Integrity Manager positions. Its functions have ranged from data analysis, drafting joint operating agreements, report writing, developing fraud leads, making oral and written presentations to law enforcement as part of their case development efforts and use of databases managed by the PSC, and performing due diligence during two major transitions of operations and personnel from long-standing incumbent organizations to the new PSC organization of which Lifecare was an integral part. A significant portion of Lifecare’s professional work over the past eight years has been performed for or involved in a professional relationship with the Office of Inspector General (OIG) for the Centers for Medicare and Medicaid Services (CMS), the Resolution Trust Corporation (RTC), the Federal Deposit Insurance Corporation (FDIC), and law enforcement entities (e.g., Federal Bureau of Investigation, Assistant United States Attorneys). In the performance of its work, Lifecare has processed confidential and sensitive data related to injured Federal workers, Medicare providers, suppliers and beneficiaries, IRS employees, contractor billing and service agreements, and civil litigation matters.
Lifecare was formed in March 1995 as a District of Columbia General Partnership. Initially, it was intended to assist Federal agencies to better manage their human resource/program integrity initiatives through the use of new technologies, new case management tools, centralized management of nationwide programs, innovative return-to-work strategies, and effective employee training programs. In September 1995, Lifecare executed its first government contract with the Federal Aviation Administration (FAA) to assist the agency over a five-year period, in dealing with complex workers compensation, labor management, and employee benefit issues (including work and family life issues). Under a pilot program, Lifecare established a centralized claims center to manage new workers compensation claims from three FAA regions involving 18,000 employees. Lifecare was the first private industry contractor to provide comprehensive nationwide management support in the administration of the Federal Workers Compensation program. Prior to implementing day-to-day case management, Lifecare developed and prepared implementation plans and standard operating procedures, including compliance with the Privacy Act. Lifecare also undertook surveys of “best practices” and completed an intensive computer analysis and stratification of workers compensation data.
Under a separate task order, Lifecare provided assistance to FAA’s New England region in the implementation of organization system effectiveness and re-engineering training. This task order provided for consultation and facilitation services to FAA with the goal of increasing the organizational system effectiveness of the New England regional organization through the integration of team building processes into the core business processes.
In March 1997, the U.S. Department of Housing and Urban Development, after a full and open emergency solicitation, awarded a short-term contract to Lifecare to manage its workers compensation program nationwide for approximately 11,000 HUD employees. Under the contract, Lifecare established a dedicated service center to coordinate and manage all of HUD’s claims. In January 1998, Lifecare was awarded a five-year small business contract with HUD to continue the operation of the Claims Center. Lifecare was successful in winning this competitive procurement because of Lifecare’s outstanding technical experience dealing with Federal workers compensation issues and designing innovative strategies to assist injured employees. In March 1998, Lifecare was admitted into the U.S. Small Business Administrations 8(a) business development program. In October 1998, Lifecare was awarded, after a full and open competition, a contract with the Internal Revenue Service (IRS) to conduct nationwide investigations of alleged IRS employee administrative violations (taxpayer abuse). The IRS selected two task order contractors to perform these services.
Lifecare for 15 years operated a centralized Federal Workers Compensation claims processing center for a number of Federal agencies including FEMA, HUD, and the National Gallery of Art. Lifecare also performs other Federal Workers Compensation Services for the U.S. Drug Enforcement Administration and the Department of Home Land Security, Customs and Border Security. Lifecare’s work covers Federal agencies and employees in all 50 states. Mr. Molina’s experience as an attorney has been invaluable in developing strategies to reduce agency costs, identify subrogation opportunities, reduce fraud and abuse and, at the same time, improve services to agency employees. All personnel performing daily case management functions on these contracts are known for their timeliness, diligence, and perceptiveness.
For Walter Reed Army Medical Center and the Army clinics at the Pentagon and Aberdeen Proving Ground, Lifecare fulfilled all of their outsourced technical positions for clinical coding, compliance auditing, training of healthcare providers in medical record documentation and related clinical coding, development of templates and technical materials to be used in clinical practices to ensure optimal workload reporting and billing for third party reimbursement, and provide related project management and support to military management for implementation of new program requirements.
On September 28, 2004, Lifecare Management Partners was awarded the Comprehensive Error Rate Testing (“CERT II”) task order by the Centers for Medicare and Medicaid Services (CMS).
CMS, Office of Financial Management, Program Integrity Group, developed a program called the Comprehensive Error Rate Testing (CERT) program that produces national, contractor specific, service specific and provider type paid claim error rates. The program calls for a CERT contractor, herein after referred to as CERT I, to select a random sample of claims from the claims processing system at the Affiliated Contractors (ACs), request and receive medical records from the billing provider, review the medical records to see if the claims were paid or denied correctly, and produce error rate reports. CMS has chosen to contract with an additional CERT contractor (CERT II), which will, among other things:
Request and receive approx. 120,000 medical records each year from Medicare providers across all claim types for review by CERT I;
Gain more error rate data about specific service types that cannot be estimated from the current sample by performing Special Studies/medical reviews such as Skilled Nursing Facility (SNF) Demand and Home Health Agency (HHA) demand bill special studies, etc.;
Establish a mechanism with which to mitigate unexpected fluctuations in the CERT I contractor’s processing requirements, i.e., transfer some of the tasks currently performed by the CERT I contractor to the CERT II contractor.
In 2005, CMS awarded a similar contract to Lifecare for the collection of medical records related to the new Medicaid Payment Error Rate Measurement (PERM) program. The initial sample involved 17 state Medicaid programs.
In 2003 Lifecare established a Workers’ Compensation Review Center (WCRC) for CMS. Under this contract, over a 9 year period, Lifecare reviewed all Medicare Set Aside Agreements submitted to CMS. For each agreement, Lifecare reviewed and audited extensive medical documentation and provided CMS with an independent evaluation on future Part A, Part B and Part D drug costs related to the impacted Medicare beneficiaries. During the duration of the contract, Lifecare reviewed over 150,000 set aside agreements that resulted in, well over, $2 billion dollars of savings to the Medicare Trust Fund.
Lifecare’s Medical Review Center (MRC) is currently conducting medical record claim reviews and appeals in support of CMS and it’s Medicare Administrative Contractors (MACs). Our MRC is housed in a 22,000 sq. ft. facility with four office suites, a training center, a data center and an IT infrastructure compliant with CMS security requirements.
We are staffed with experienced reviewers including nurses, certified coders and other individuals with certifications and medical degrees. Our staff is experienced in Medicare Part A and Part B coverage and payment policies, including medical necessity reviews and DRG validations. The MRC also includes management, supervisory, quality assurance and
IT staff to support ongoing medical review operations. Our IT staff includes a systems security officer (SSO) and network engineers to establish and maintain secure links to our customer sites. In addition, our Medicare subject matter experts are available to assist customers with the development and implementation of their medical review strategies.