To celebrate National Nurses Week, we are shining a light on the dedication and expertise of these medical professionals who play a vital role in healthcare. Palmetto GBA is fortunate to have a dedicated team of more than 700 nurses. Every day their clinical experience helps them ensure claims, processes, procedures and equipment meet the high standards of the Centers for Medicare & Medicaid Services (CMS).

Nurses are the backbone of several key departments, including Medical Review, Appeals, Medical Affairs, Pricing, Data Analysis and Coding (PDAC), Quality Assurance and Provider Outreach and Education and corporate leadership. Each department requires a unique set of skills and knowledge.

Medical Review

Palmetto GBA’s Medical Review Department includes more than 500 nurses who review medical documentation to ensure the Medicare trust fund is protected from improper payments and to help combat waste, fraud and abuse. They review Medicare claims for Part A (inpatient hospital, biological drugs, nursing home, etc.), Part B (physician visits, labs, outpatient therapy, etc.) and Home Health and Hospice for compliance with the Medicare Benefit Policy Manual. With diverse clinical backgrounds, our nurses bring a wealth of expertise to provide detailed medical reviews.

Appeals

The Appeals team nurses play a crucial role as advocates for patients whose claims have been denied. They assess medical records to determine if the billed services meet Medicare coverage and billing requirements, gather additional medical evidence, prepare detailed appeal letters and liaise with healthcare providers, insurance companies and legal counsel. Staying up to date with regulatory guidelines, they ensure that every decision is fair and well-explained.

Quality Assurance and Provider Education

Nurses in several departments serve as educators and quality assurance experts. They provide training for internal staff and external healthcare providers, review medical claims, and participate in quality assurance activities. When providers call with complex questions, the questions are passed along to nurses who are quick to research and respond, often on the same day. Their strong communication and customer service skills make them invaluable. Some nurses also serve as preceptors, training new medical reviewers through the Preceptor Pal Program.

PDAC and Medical Affairs

The PDAC team assists suppliers, manufacturers and distributors in the proper use of level II Healthcare Common Procedure Coding System codes for Durable Medical Equipment Prosthetics Orthotics and Supplies for Medicare billing purposes. Medical Affairs Coordinators manage decisions about Medicare coverage, maintain lists of covered services and facilitate communication between departments and Contractor Medical Directors.

At Palmetto GBA, we celebrate National Nurses Week to honor the vital role our nurses play within our organization and also to showcase the important role they play in community health and across all segments of the healthcare delivery system.