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Prepayment Review

Ending Medicare and Medicaid medical record prepayment review.

Sade & Zuniga Medicare Consulting, Inc., has assisted numerous physicians in Florida, Texas, New York and California with being removed from Medicare prepayment review, and having Medicare payments continue while on prepayment review.

Under the prepayment review process, Medicare contractors identify claims and codes with patterns of errors and investigate their merit before paying the submitted claims. Instead of paying claims when billed by the physician, Medicare mails a letter to the physician requesting a copy of the medical records documenting each billed service.

A Medicare nurse reviews the submitted medical records and makes a determination if the claim will be paid or denied. The decision to pay or deny the claim is based on whether the submitted medical records meet the documentation and medical necessity requirements listed in the Medicare Local Coverage Determinations (LCD) for the service or procedure billed.

Most of the claims reviewed by Medicare as part of prepayment review are denied because the Medicare nurse decides that the submitted medical records do not meet the documentation and medical necessity requirements.

 

The following 4 step process is the only way to be removed from Medicare prepayment review.

Step #1:
Sade & Zuniga Medicare Consulting, Inc., reviews the physician’s medical records in-order to determine if records meet the documentation and medical necessity requirements listed in the Medicare Local Coverage Determinations (LCD).

 

Step #2:
Sade & Zuniga Medicare Consulting, Inc., educates the physician on the Medicare documentation and medical necessity requirements listed in the Medicare LCD, and what required information is missing from the physicians medical records.

 

Step #3:
As soon as the medical records meet Medicare guidelines Sade & Zuniga Medicare Consulting, Inc., appeals all denied claims and acts as your “representative” during the entire appeals process including the first level redetermination, second level Reconsideration and third level Administrative Law Judge (ALJ) hearing.

 

Step #4
Sade & Zuniga Medicare Consulting, Inc., communicates with Medicare and works on the physicians behalf to get the physician removed from prepayment review.