Medicare (PPS & Part B)


The Harmony Healthcare International (HHI) Medicare audit process is an intensive detailed review of the medical record content for medical record accuracy, compliance concerns in addition to potential clinical opportunities. The Medicare site visit process includes Medicare Part A and Part B medical record analysis, on-site education for all appropriate staff, an exit conference, in addition to a comprehensive written report.

The report generated by the HHI Consultant following the facility visit is a communication tool used to convey findings and recommendations.  The purpose of the report is to educate the staff on the rules and regulations encompassing patient care in a nursing facility. In addition, the report provides clinical guidance to ensure that all patients receive clinically appropriate care.

Potential Risk to Providers:

In fiscal year (FY) 2012, Medicare paid $32.2 billion for SNF services. The Office of Inspector General (OIG) has identified a number of problems with SNF billing. Notably, OIG found that 26 percent of claims submitted by SNFs in FY 2002 were not supported by the medical record, representing $542 million in potential overpayments   Recent OIG investigations have also found problems with SNF billing. For example, one SNF reached a settlement agreement on allegations of fraudulent billing for medically unnecessary therapy.

How can Harmony Healthcare International (HHI) help?

The objective of Harmony's Medicare Audit site visit is to review the medical records for information that supports the clinical services provided and documented on the MDS as they relate to RUG-IV and outpatient Part B reimbursement. In addition this process investigates for compliance employing CMS rules and regulations using a retrospective and current caseload sample. All recommendations, provided by HHI, are based on patient specific, clinically indicated services combined with the supporting documentation. HHI identifies areas of opportunity based upon direct caregivers observations, staff interviews, and clinical assessments along with review of medical record documentation. HHI's recommendations impact the facility’s internal processes and thus impact the revenue cycle. Our goal as HHI Consultants is to insulate the facility’s revenue stream while educating the clinical team in the process of case management in accordance with Medicare SNF guidelines. With these shared tools and monthly oversight for accountability built into the system, goals will be attained.

Free RUG Analysis - Compare your facility's utilization with current national CMS data