Understanding Payer and Recovery Auditor Denial Tactics

Course Description:

Hospitals are under ever-increasing financial pressures yet are expected to consistently achieve excellent patient care results. However, for several decades, the cost of providing care has only increased while hospital reimbursements have remained fairly flat. Therefore, maintaining financial solvency has become increasingly difficult for hospitals to continue their patient care missions. As the healthcare dollar shrinks for all parties involved, the frequency of hospital payment denials and previously obtained reimbursement recoupments has skyrocketed. Additionally, the administrative burden of appealing payer and recovery auditor denials has correspondingly increased further straining hospital resources. In this session, the most common initial payment denial and post-payment recoupment strategies utilized by CMS, its various contractors, and the commercial payers will be reviewed. Understanding how a payer or recovery auditor searches for and then issues any denial is the first step to developing an effective and coordinated denial prevention strategy. As denial prevention is infinitely cheaper and significantly easier than fighting through the cumbersome and lengthy appeals process, hospitals should focus more of their efforts on denial mitigation. This can only be undertaken with a thorough and in-depth understanding of the denial weapons deployed against your organization.

Learning Objectives:

• Learn why your hospital is a denial target
• Learn the most utilized denial strategies deployed against hospitals to prevent and recoup reimbursements
• Understand how provider documentation is a critical factor for facilitating hospital denials and preventing future denials
• Understand how Observation vs. Inpatient status impacts hospital reimbursement and denial risk
• Identify why hospital status is a common target for payers and auditors
• Learn what MS-DRGs are and why certain MS-DRGs are frequently targeted for downgrades
• Understand how MS-DRG downgrades are carried out to recoup payments
• Define Medical Necessity and how it is used to justify denials and recoupments
• Learn how proper documentation can help prevent Medical Necessity denials
• Understand why proactive denial prevention is more effective than lengthy appeal

Areas Covered in the Session:

• What is Hospital Status (OBS vs. IP) 
• Why is hospital status such a problematic and contentious issue 
• How lax provider documentation facilitates status denials 
• What is an MS-DRG 
• Why and how are certain MS-DRGs targeted 
• What is an MS-DRG downgrade 
• How MS-DRGs are most commonly downgraded 
• What does Medical Necessity mean 
• How Medical Necessity denials can be prevented
• Live Q&A Session

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Suggested Attendees:

• Hospital CFOs
• Revenue Cycle Department Members
• Appeals Coordinators
• Clinical Documentation Integrity Specialists
• Hospital Case Managers
• Healthcare Administrators
• Physicians and Non-Physicians Providers
• Medical Coders
• Billing Specialists
• Gastroenterologists
• Clinic Managers
• Nurses
• Experienced Coders
• Experienced Billers
• Clinicians
• Medical Billers
• Healthcare Compliance Officers
• Clinical Documentation Specialists
• Practice Managers
• Health Information Managers
• Medical Office Managers
• Medical Auditors
• Revenue Cycle Analysts
• Medical Reimbursement Specialists
• Coding Educators

About the Presenter:

Trey La Charité, MD, FACP, SFHM, CCS, CCDS, is the medical director for CDI, Coding, and Utilization Integrity at the University of Tennessee Medical Center in Knoxville. He is a practicing hospitalist for over 20 years, is a clinical associate professor in the Department of Medicine and is the curriculum director for their residency program’s hospitalist rotation. He has additional responsibilities spanning case management, UR, compliance, quality, performance improvement, and medical records. A past and current ACDIS Advisory Board member, he is a regular presenter at the annual ACDIS meeting and the pre-conference Physician Advisors Forum. He has written several books in the field of CDI that address physician advisor training, program management, and recovery auditor appeals.

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

Live Course Cancellation Policy: If for any reason Skillacquire need to cancel this program, Skillacquire will notify participants by email of the cancellation no less than 24 hours prior to the expected start time.

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

Snippet From Our Previous Session:

FAQ:

1. Live Access:
   • For individuals who want real-time participation.
2. On-Demand Recording:
   • Best for flexibility and learning at convenience.
   • Forever access with unlimited views and resources.
3. Flash Drive + Replay:
   • Physical flash drive with full webinar recording.
   • Ownership with bonus forever digital replay access. 
4. Live + On-Demand Bundle:
   • Covers both live interaction and future reference.
   • Includes live session participation and forever on-demand access. 
5. Live + Flash Drive + Replay:
   • Physical flash drive with full webinar recording.
   • Permanent ownership, with bonus forever digital replay access.
   • Includes live session participation for real-time engagement.
6. E-book Format:
   • Comprehensive written guide with power point slides and visual references.
   • E-Book will be sent after the Live Session is done.
   • Ideal for learners who prefer reading over watching videos.
7. Corporate/Team Access:
   • Ideal for teams (up to 10 members) looking for a shared experience.
   • Live or on-demand access with team dashboard and group certificates.

Testimonials:

"This program on HIPAA did a great job providing actionable concepts in a way that updated our team and me, I now know how I will implement the concepts because I already did it in their online seminar, it was easy to ask questions from the speaker at the end of my 60 minutes course"

Melissa Preston, Health Information Management Staff

"David Vaughn covered the material completely and I have a new understanding of when, where and why we need to use an ABN" 

Sandie Fowler, Out of Network Billing Staff

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

Tina Duffy, Compliance Officer