by Proactive LTC Consulting | Jul 16, 2025 | ADR, Appeals, Audits, Documentation, Medical Review, Medicare, Reimbursement, SNF
Q: Do we need to obtain prior authorization for every managed care resident who requires skilled services, even if they clearly meet criteria? A: Unfortunately, yes — at least for now. Most managed care plans (including Medicare Advantage) still require prior... by Proactive LTC Consulting | Aug 9, 2023 | Appeals, Medical Review, Medicare, Q&A
Q: My facility is going through a Medicare UPIC review and received a significant number of denials followed by a demand letter requiring repayment. What are our options for appealing the decision and what is the interest rate that will apply if we aren’t able to... by Proactive LTC Consulting | Oct 19, 2022 | Appeals, Q&A
Q: How much is the ALJ Appeal Amount in Controversy for 2023? A: The amount in controversy (AIC) threshold amount for Medicare ALJ appeals will continue to be $180.00 for CY2023 and the AIC for Judicial Review will increase to $1850.00 Learn more Angie Hamer,... by Proactive LTC Consulting | Oct 18, 2021 | ADR, Appeals, Audits, Blog, Medical Review, Medicare
Are your processes achieving accurate CMI reimbursement for the care that your staff delivers? The case mix index is intended to reflect the type of residents being treated and the level of care required. Therefore, it is important to ensure that procedures are in... by Proactive LTC Consulting | Oct 6, 2021 | ADR, Appeals, Audits, Blog, Medical Review, Medicare
Wrongful death claims pose a significant concern for healthcare facilities. In a 2019 review of claims, roughly half of fall-related claims involved a death and 62% of closed claims involved death related to pressure injury with total payments related to pressure... by Proactive LTC Consulting | Sep 29, 2021 | ADR, Appeals, Audits, Blog, Medical Review, Medicare
The Centers for Medicare & Medicaid Services (CMS) indicated in an August 2021 MLNConnects newsletter that the targeted probe and educate (TPE) program would resume ending the temporary suspension since in place since March 2020 due to the COVID-19 public health...