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AMDA's 2015 Annual Conference


B35 - Determining "Medical Necessity" in an Government Review of Skilled Nursing Facility Records


Mar 20, 2015 11:00am ‐ Mar 20, 2015 12:00pm


Credits: None available.

Standard: $24.00

Description

Accreditation Statement: AMDA – The Society for Post-Acute and Long-Term Care Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation Statement: AMDA – The Society for Post-Acute and Long-Term Care Medicine designates this Internet Enduring Material for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

ABPLM Designation Statement: This Internet Enduring Material has been pre-approved by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM) for a total of 1 management hour toward certification as a Certified Medical Director (CMD) in post-acute and long-term care medicine. The CMD program is administered by the ABPLM.  Each physician should claim only those hours of credit actually spent on the activity. 

Session Description:
As a legal expert for the Department of Justice and other government agencies in skilled nursing facility (SNF) fraud cases, the presenter will explain the government's point of view, discuss how a determination is made, and what the medical director's responsibility is in these government probes. The session will describe different types of government probes, explain the False Claims Act and how it's used against SNFs, review recent cases and outcomes, and provide steps to take when faced with a government probe.

Learning Objective(s):

  • Compare possible government audit types: Recovery Auditor (RAC), Medicare Administrative Contractor (MAC), Zone Program Integrity Contractor (ZPIC); Department of Justice (False Claims Actions), procedures and possible outcomes
  • Examine role of physician/nap documentation in substantiating "medical necessity" in a SNF Medicare clinical record during any government probe
  • Examine recent cases in which the government successfully brought False Claims actions against nursing facility owners for substandard quality of care and/or Medicare/Medicaid fraud

Speaker(s):
Judy Wilhide Brandt, RN

Disclosure(s):
None

Reference(s):
Medicare Manuals, Code of Federal Regulations

Speaker(s):

Credits

Credits: None available.

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