Medicare and Medicaid Medical Necessity Compliance

Medicare and Medicaid Medical Necessity Compliance

Managed Care and Commercial Admission Review and Denials Management

We specialize in Medicare and Medicaid Medical Necessity Compliance, Managed Care and Commercial Admission Review and Denials Management running a current needs analysis of the organization and based on current regulations, help the Case Management and Utilization Review departments with formulating defensible statement letters that look at the patient globally.

Our determination letters include

  1. Case Summary: Includes chief complaint and summary of clinical events detailing medical necessity and severity of illness
  2. Bedding status recommendation: Inpatient or Observation
  3. Audit Risk Score: Calculated using proprietary Aerolib Analytics, this gives an estimate of the risk of an audit
  4. At Risk Reimbursement: based on DRG, LOS and billing submissions from existing hospital data and Medicare payments for region
  5. Interventions to decrease Audit Risk Score