Medical Necessity: Stop Denials to Prove Claims Deserve to be Paid

Course Description:

This webinar will demonstrate how to accurately and proactively be prepared for audits should your records be pulled for additional review. Understanding the requirements for payment from payers can be strenuous from private payers. We will show you the best way to document services in a manner of which third party reviews should be able to decipher the needs to make claims payment. It’s important to understand when documentation is easier to read, it becomes less of a challenge to pay.

Knowing what is meant by "medical necessity" is essential for a healthcare provider to be paid appropriately and to prevent being accused of overpaying in the event that Medicare or another payer asks for supporting proof for submitted claims. Physicians and nonphysician practitioners who document services requested or rendered, along with coders and billers who file claims, must all have a solid understanding of how payers determine medical necessity. In addition to discussing how to apply recent findings from CMS contractors like the CERT contractor and specific Medicare Administrative Contractors for proper reimbursement, this webinar will cover how to decide what documentation to submit in response to a payer's request for records.

Learning Objectives:

Know CMS documentation requirements for services provided
Understanding the requirements for payment from payers
Learn appropriate documenting for same day procedures using modifier 25
Identify when additional payment is needed when using modifiers (24, 25, 59. 76, 78)
The best way to answer queries and how to reduce of the amount of queries written
For services requiring escalation of care, using your documentation to prove escalation of care is needed
Reducing the burden of which guidelines to follow when submitting for preauthorization

Areas Covered in the Session:

How CMS describes medical necessity as the overarching criteria?
What should be included in your documentation?
CMS and other payer rules and requirements
Proving medical necessity with payers
Documentation for minor/major procedure
When medical necessity was reviewed and was approved/denied based on supporting documentation
What can providers do to help prove claims deserve to be paid when submitting for payment with appropriate modifiers and/or multiple procedures, including
- 80 - Assistant Surgeon
- 62 - Co-Surgeons
- 51 - Multiple procedures
- 59 - Distinct procedural services
- 78 - Unplanned Returned during post op
- 79 - Unrelated procedure during post op
CMS documentation requirements when using modifiers and their distinct requirements
Prepare system in place when billing to assure all services are billed appropriate
When not to bill if services are not supported?
Live Q&A session

Suggested Attendees:

Healthcare CEOs
Healthcare CFOs
Healthcare COOs
Healthcare Providers
ASC Directors
Office Managers
Administrators
Policymakers
Billing Staff and Companies
Physicians and Other Providers
Healthcare Consultants
Hospital Director
Software Developers
Compliance Officers
Mid-Level Providers
Physicians
Coders
Billers
Clinic Managers
Nurses
Practice Manager
Office Managers
Reimbursement Managers and Staff
Other Staff Involved in the Telehealth Services

About the Presenter:

Maya Turner, CPC, CPMA, CPCO, CFPC, CPC-I, AAPC Approved Instructor has nearly 30 years of experience in revenue cycle management, coding compliance and education. Maya’s dynamic teaching style and unparalleled expertise will undoubtedly enrich the learning experience for our participants, ensuring a comprehensive and engaging educational journey. A seasoned certified coder and auditor, boasting of nearly 30 years of experience and subject matter expert to many coding compliance subjects, she especially is sought after for her in depth knowledge base of pro fee multi-specialty practice, primary care, hospitalists, telehealth, inpatient, as well as SNF. She is also a published author having written articles for AAPC and HCCA, and currently is a part of the ACDIS Leadership Council. She’s scheduled to speak at such venues as HealthCon, and HCCA’s Compliance Institute.

She showcases her unmatched three-dimensional thinking in complex subject matters, Maya's success is marked by her clear and well received presentation style, reflecting her profound understanding and expertise. Maya also has a consulting service called Turner Expert Consulting Services, LLC. This venue allows her to assist other entities and provide training and expertise outside of her current employer. It’s with this, bringing her great joy to assist others in any way she can.

Additional Information:

After Registration: You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.

System Requirement:

Internet Speed: Preferably above 1 MBPS
Headset: Any decent headset and microphone which can be used to talk and hear clearly

Can’t Listen Live?

No problem. You can get access to an On-Demand webinar. Use it as a training tool at your convenience. For more information, you can reach out to the below contact:
Toll-Free No: 1-302-444-0162
Email: care@skillacquire.com

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Melissa Preston, Health Information Management Staff

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Sandie Fowler, Out of Network Billing Staff

"Great presentation. Able to do during the day. Timing was great"

Tina Duffy, Compliance Officer

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