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Concurrent Medical Necessity Reviews

Concurrent Medical Necessity ReviewsCMC Physician Advisors are skilled in the area of Medicare and Medicaid rules and regulations pertaining to observation and inpatient status and provide the required secondary, concurrent physician review of Medicare/Medicaid observation status cases and inpatient admissions that do not meet case management’s medical necessity screening criteria.

The CMC admission review process utilizes evidence-based medicine and CMS guidance in order to ensure appropriate admission status certification, complete chart documentation, the highest level of compliance with CMS rules, and revenue integrity. Learn more »»

 

Retrospective Clinical Denials Management

Retrospective Clinical Denials Management Case Management Consultants provides specialty trained physician advisors to assist hospitals in retrospective clinical denials management including third-party payors DRG Audits.

CMC Physician Advisors are available to perform retrospective clinical denial review, and provide expert independent physician advisor representation throughout the third-party payors review and denial management process.

CMC Physician Advisor are available at short notice to assist hospitals and health systems in responding to third-party payors request for clinical information in order for the hospitals to be in compliant with the deadline for responding to request for clinical information. Learn more »»

 

RAC Audit Program

Medicare Recovery Audit Contractor Case Management Consultants provides specialty trained physician advisors to assist hospitals in medical necessity review, admission review, and procedure setting review.

The Medicare Modernization Act of 2003 established the Medicare Recovery Audit Contractor (“RAC”) program as a demonstration program to identify improper Medicare payments – both overpayments and underpayments. RACs were paid on a contingency fee basis, receiving a percentage of the improper overpayments and underpayments they collect from providers. In July 2008, Centers for Medicare and Medicaid Services (“CMS”) reported that the RACs had succeeded in correcting more than $1.03 billion in improper Medicate payments. Learn more »»

 

Case Management Programs

Case Management ProgramsThis program is designed specifically to coordinate and manage the care of medically complex patients, recently discharged from hospital, to prevent re-admissions and/or frequent emergency room visits. The Transition of Care Management Program arranges medical care for patients within the first 30 days of discharge.

A team of physicians and case management nurses will collaborate with physicians, treatment facilities and family members regarding treatment plans and ongoing care coordination needs for the patient. This includes ongoing monitoring for exacerbations and new conditions, as well as recommendations to primary care and home care physicians on medically necessary interventions. Learn more »»

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