Medical Claim Review and Appeal Support
In 2005 Lifecare established a Workers’ Compensation Review Center (WCRC) for the Centers for Medicare and Medicaid Services (CMS). For over seven years 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. Over 150,000 Set Aside Agreements were reviewed resulting in cost avoided savings of $2B to the Medicare Trust Fund.
Lifecare opened its Medical Review Center (MRC) in 2012 to conduct medical record claim reviews and appeals. Our MRC campus consisted of three secure office suites totaling 22,000 square feet. The MRC has been staffed with experienced reviewers including nurses, certified coders and other individuals with certifications and medical degrees. The MRC also included managers, supervisors, quality assurance and IT staff to support ongoing medical review operations. Our systems security officer (SSO) and network engineers have established and maintained secure links to our customer sites. The MRC was equipped to handle the medical review of initial claims as well as appeals. In addition, our Medicare subject matter experts were available to assist customers with the development and implementation of their medical review strategies. More than 190,000 claims and appeals were processed in our Medical Review Center.
Lifecare’s MRC staff performed medical claim reviews, appeals and other support services to support Medicare Administrative Contractors (MACs). These reviews included Medicare Part A and B claim medical necessity and coverage determinations and provider appeals, as well as DRG and other coding validations. We maintained the capacity to quickly expand our operations to support additional Medicare contractors and other organizations needing claim review services. Our proven project management and implementation skills allowed us to quickly ramp-up to meet the timeliness and production priorities of our customers.
Under its PSC IDIQ contract, Lifecare continues to perform work for the CMS Comprehensive Error Rate Testing Program (CERT). Under this initiative, Lifecare is responsible for the procurement of medical records from providers whose claims are selected for CERT medical review. Lifecare has been responsible for the successful procurement, scanning and control of over 120,000 provider medical records per year.
In 2005 Lifecare established a Workers’ Compensation Review Center (WCRC) for CMS. For over seven years 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.
Medical review of Medicare Part A & B claims for a MAC contractor. Lifecare’s clinical staff evaluated claims for appropriate coding and payments.
Independent medical review of Medicare Part A provider submitted appeals challenging RAC claim denials. Lifecare clinicians determined the medical necessity and appropriateness of care by evaluating applicable coverage payment policies and procedures resulting in a favorable or unfavorable outcome.
Lifecare was engaged by a MAC to review Medicare Hospice claims to determine the eligibility for payment based on the patient medical record and Medicare’s payment policies and guidelines.
Medical review of Medicare Part B claims to support ZPIC fraud investigations. Lifecare Nurse Analysts investigated claims to prevent potential fraudulent billing.