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.
Workers’ Compensation Review Center (WCRC)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.
MAC Medicare Part A & B Medical Claims ReviewMedical review of Medicare Part A & B claims for a MAC contractor. Lifecare’s clinical staff evaluated claims for appropriate coding and payments.
MAC Medicare Part A RAC AppealsIndependent 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.
MAC Medicare Hospice Claims ReviewLifecare was engaged by a MAC to review Medicare Hospice claims to determine the eligibiilty for payment based on the patient medical record and Medicare’s payment policies and guidelines.
ZPIC Medicare Part B Claims ReviewMedical review of Medicare Part B claims to support ZPIC fraud investigations. Lifecare Nurse Analysts investigated claims to prevent potential fraudulent billing.
Program Integrity Support
Medicare/Medicaid program integrity support is also a Lifecare core competency. Lifecare has served CMS as both a prime contractor and a principal subcontractor in its anti-fraud and abuse initiatives. As a prime contractor, Lifecare was awarded a CMS task order to review nebulizer drug payments in 17 states. As a subcontractor on four PSC task orders, Lifecare provided legal counsel, investigative and data analysis services and support.
DMERC Region C Support for Nebulizer Drug ReviewLifecare was awarded a contract to support the CMS and OIG sponsored Drug Nebulizer Review Project to identify potential fraud or abuse and to establish a payment error rate. Lifecare’s role included performing medical reviews of Medicare claims, conducting on-site audits of suppliers and interviewing prescribing physicians, as well as beneficiaries receiving the services.
PSC Contractor SupportLifecare performed PSC contractor support including Fraud Detection and Investigations, Data Analysis and Chief Legal Counsel services
ZPIC Contractor SupportLifecare performed ZPIC contractor support in the areas of IT Network, System Security and Medical Claims Review services.
Our program integrity staff are available to assist customers with fraud, waste and abuse initiatives including data analysis, investigations, provider risk assessments, background checks, risk scoring and surveillance.