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Words of Wisdom from Michael McGowan

It’s the end of another long day of reading clinical records for ZPIC clients and while I would like to write a post or two, extra time has been precious and scarce these days. So, join me in thanking Michael McGowan, colleague and mentor in the Zone for sharing his experience with Zone Contractors. His contact information is below so please email him with questions about the big words he uses! And of course, you may always post below in the comments section.


Wow what a feeling!!

I have talked to potential clients as they are actually having chest pains and snacking on nitro tabs or spray as they describe this over the phone to me. 

They have just been selected amongst an elite group of many who during the last 36 months have submitted via billing, OASIS, Service Utilization, and other data to the folks at CMS from which a data profile was created. This pattern has been confirmed by the computers as having a 90% or greater chance of containing errors allowing CMS to recover several million dollars from you. (More of that another time)

The data is so compelling that it leaves CMS no other option than to validate what you’re doing; Via a post payment review.

 So you have a letter.

CMS is fishing for money.

No denial of payment has been made as of yet.

A lawyer will do what at this point?

A consultant will do what at this point?

What can you, the agency owner do for FREE? The answer is an amazing amount, and most owners properly coached need very little intervention until the midpoint of the process.

It is actually more important to build a financial rainy day fund at this point than spend like a sailor.

Everything that needs to be done at this point can be done by you, auditing of the census and the charts to look for the data patterns that triggered this fiasco, identifying the documentation patterns that will be denied, and perform a sample extrapolation from your global universe of claims to validate and assess your liabilities.

Rather simple low-level activities. (An aside from Julianne to Michael: Not everyone has MBA behind their name. These activities are simple if you know what your global universe of claims is and how to extrapolate. Note to readers: Extrapolation is akin to a root canal without anesthesia in terms of the level of discomfort it causes. Think 20 on a standardized pain assessment of 1 – 10.)

 So we now know that if you’re the recipient of this type of probe there will be financial losses at some point in time. Certainly not until charts are reviewed, as the law does not allow for the debit of money, until charts are approved and or denied.  So calm down take a deep breath. This is not the end of the world, but it will not go away either. Some of you will need to go to the gym and work it out; others will resort to a few drinks whilst others will bury their head in the sand.

After working through the demonstration project on the west coast with post payment reviews the past six years I can assure you this…

We have never lost a soldier and what does drop you to your knees will make you stand stronger for the long term if you properly position yourself.

Best of luck to all of you


Michael McGowan. MBA/HCA 
Senior Consultant, CEO 
Medicare Appeals Development,LLC

2 Comments Post a comment
  1. Millicent #

    Very interesting. I have an interest in working with Medicare Appeals/RAC etc. What is the process for employment in this sector?

    April 13, 2011

    • It all depends on which side of the fence you want to play. If you want to play with the contractors who audit charts, contact them. They use clinicians for complex reviews including RNs and LPNs. If you want to consult for agencies being investigated, the requirements are: nerves of steel, patience, ability to stay up very, very late and lots of creative writing skills. You must have the ability to choose clients very carefully and be able to identify the good guys getting slammed who need help vs the bad guys who will take you down with them. Michael, do want to add anything?

      April 13, 2011

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