Medicare Appeals Development
Audit Tool Directions
This is a financial audit Tool
Medicare is not an insurance company. Medicare is as an act of law, signed by the Congress,
Senate, and President. As such, the authority for what you do in your day-to-day practice in home
health is derived explicitly from the laws below, nowhere else.
42 CFR (Code of Federal Regulations)
SSA sections 1816 Et Al... (Social Security Act) http://www.ssa.gov/
42 U.S.C 1395 Et Al... (United States Code of Justice)
#1 http://www.law.cornell.edu/uscode/ #2http://www.gpoaccess.gov/uscode/
CMS PUB 100-2,7 (Medicare Benefit Policy Manual)
Medicare, when enforcing the parameters of its contractual requirements from the
subcontractor, will use nothing but the law. With Medicare, you have the obligation of the law and a
contract to satisfy. If you do not know the above, how do you satisfy the requirements in your agency?
Professional auditors performing BI, ZPIC, PSC, RHHI audits use blank tools such as this and
perform an analysis of each and every patient encounter as they "Interpret" what they see in the
documented visit activities in comparison with the regulations listed above.
It takes the average auditor 12-18 months to learn this professional skill set. It is necessary for
you as home health professionals to understand this information at an equal or better level than the
auditors who inspect your work.
Remember three years of closed charts are the playing field here. This tool and these references
are what you need to catch up, and stand a chance at being competitive. Why risk $100 - $400
thousand dollars or more.
If you so need I am available to teach this process.
Happy auditing and best wishes,
Michael Mcgowan MBA/HCA
Medicare Appeals Development, LLC
Mr. McGowan was an OASIS Coordinator for the State of California. He monitored and
interacted with 700 Home Health Agencies and 450 state surveyors in 24 district offices on a daily
basis, and as a liaison between Home Health Providers, State government, Region IX CMS, and CMS
Baltimore on a weekly basis.
As an OASIS coordinator, he has an extensive nursing background, Informatics/Computer technology
background, and was charged with assisting in computerized survey activities in the home health
community. Microscopically probing and scrutinizing the provider community and relaying the
information to different entities requesting various data profiles, reporting deficiencies and anomalies
in provider behavior. This resulted in numerous surveys, closure, and enforcement activities.
Having taught the data driven survey techniques during national CMS survey training sessions, and
surveyors in 24 district offices. Mr. McGowan is intimately familiar with what goes on behind the
scenes. It is the "Insider Knowledge" that cannot be mimicked or recreated. Either you have done this
type of work or your guessing about it, experience cannot be replaced.
Mr. McGowan utilizes his unique data driven perspective from the federal sector to analyze agencies
with a microscope allowing him deep insight to the root problems discovered. Very few people have
left the federal sector with this knowledge let alone the ability to bring it into your agency and use it to
develop customized solutions to assist you out of the challenges you face.
Being an independent non-affiliated consultant allows me to focus on my clients without the pressures
of a corporate structure to take on work for the purpose of meeting quotas. Providing "concierge
service" to my clients who are facing overwhelming challenges is what I enjoy the most about home
health. Over 97 percent of our clients have recovered funds that were previously withheld. To date, we
have recovered millions upon millions of dollars for our clients nationwide.
Medicare as an example of what we have done has displayed this appellant case.
The case is displayed on the DAB website at the following web address:
Michael McGowan MBA/HCC
Medicare Appeals Development, LLC
Chart Audit Tool
Date of Audit:
HIC Number: XXX-XX-
Dates of Service:
Patient Background Information:
Physician’s Orders:(CMS 485).
Plan of Care:
Home Health History:
Audit of Services:
Date of Type of 42 CFR
Service Services Analysis of each visit and subsequent activities MBPM
performed inside the confines of the clinician patient SSA
encounter for the visit USC
Yes / No
Based upon the foregoing, it is hereby submitted that
SN services Paid Denied Why if denied?
Presented to the PAB: Date_________
Audited by: Michael McGowan, MBA/HCA
Senior Consultant, MAD, LLC
7260 W. Azure Way # 140-80
Las Vegas, Nevada,89130