Medical Review Support
Proactive assists providers to prepare for and respond to program integrity audits. Our experts have successfully managed thousands of Medicare ADRs and Appeals, assisting providers to implement effective medical review response systems, to promote substantive charting in defense of skilled services, and to reduce error rates during government contractor investigations and payer audits.
ADR & Appeals Management Services
Proactive Consultants provide complete ADR response and Medicare Appeals management services. Proactive’s extensive medical review experience includes FCA investigation support, as well as successful outcomes with reduced overpayment liability for providers involved in RAC, UPIC/ZPIC, MAC/TPE and commercial payer reviews. Our nurse and therapist experts defend your claims with clinical evidence and regulatory references, and testify on behalf of providers in ALJ hearings.
Proactive’s MDS coding and documentation experts provide the validation and support services you need to ensure accurate reimbursement and supportive documentation that withstands the scrutiny of medical review. Our proven audit program drives coding accuracy to capture the patient-centered care you’re providing to ensure proper payment.
- PDPM Audits: Proactive has completed thousands of detailed PDPM coding and supportive documentation audits since the PDPM payment model onset, and has developed an extensive business intelligence dashboard that trends client data with the option for comparison to peer performance.
- Internal Compliance Audits: Proactive assists providers in conducting internal compliance audits involving potential overpayments
- Remote MCD Case Mix (CMI) Review
- Therapy medical necessity audits by expert PT, OT, and SLP consultants
- Medicare Risk Assessment
Proactive’s AANAC certified MDS nurse consultants offer the support your team needs to achieve your clinical assessment, coding and reimbursement goals. Proactive provides MDS orientation programs, ongoing coding support, and remote MDS coding review for optimal PDPM, CMI and QM accuracy. Annual support work plans are available with a combination of remote and onsite consultation. Learn more about our MDS support services.
Proactive Consultants offer clinical reimbursement training and systems consultation to ensure coding, billing and supportive documentation excellence. Contact us to schedule nursing and therapy skilled documentation training, ICD.10-CM coding training from an AHIMA certified trainer, new MDS orientation, RAC-CT or RAC-CTA workshops with a Master Trainer, or Medicare operational process improvement consulting.
The Proactive team has expertise with audits, new startups, ongoing reviews, setting up systems related to triple check and internal audits, as well as working with us on 5 STAR plans, and reviewing our preparation for ongoing regulatory and compliance changes. We can rely on Proactive to help us with questions, training and audits. We consider them an extra set of eyes that has our backs.
On November 20, 2023, CMS released Guidance for Federal Monitoring Surveys (FMS) which identifies the FY2024 and FY2025 focus concerns and guidance on how CMS staff will conduct FMS and communicates estimated FY2024-FY2025 required number of long-term care (LTC) FMS...
SNF Meetings– UR & Triple Check Essentials According to a recent Agency Financial Report released by the Department of Health and Human Services (HHS), the primary reasons for SNF payment error include (1) missing or insufficient documentation to support the...
Q: For PBJ, where do we allocate NP hours? A: If performing MD delegated duties report Job code 13 (see definitions below) Per the PBJ manual, Job Code 7 Registered Nurse hours include: Those persons licensed to practice as registered nurses in the...