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.
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.
As states are working to catch up on annual recertification surveys across the nation, now is a good time to review and update your education calendar for the upcoming year. During annual surveys in 2022, surveyors will be paying additional attention to compliance...
F656 Develop/implement comprehensive care plans is the #5 most cited deficiency nationally. This week’s blog examines what you need to know about the regulatory requirements related to F656 and how to avoid issues commonly cited by surveyors. There are five standard...
Ask Proactive – Let’s say I have a resident fall with injury on January 1st. How many days have to pass before it will drop off and not count against us as far as our 5-star rating?
Q: Let's say I have a resident fall with injury on January 1st. How many days have to pass before it will drop off and not count against us as far as our 5-star rating? A: The fall with major injury will be included in the QM % for the quarter if it was coded on a MDS...