QA & Medicare Compliance, Necessity Review, Dept of Justice,

Western Kentucky Division (US)

Client Issue: US Department of Justice contracted for a Medical Necessity Review of 1500 Medicare Beneficiaries medical records to determine if care was appropriately administered by nurse practitioners &/or physicians in multi-state locations within the US.

Solution: A team of nurse reviewers with quality review credentials was assembled, a customised review tool developed & implemented based on national provider standards & benchmarked quality outcomes. Coordinated cross reviews with appropriate medical billing/coding reviewers within established timeframes & delivered database as contracted.

Outcome: All records validated, outcomes reported, supporting civil & criminal actions to be taken by the Department of Justice against the provider organisation for violating Medicare standards & US law.

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