Understanding Payer and Recovery Auditor Denial Tactics
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
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
System Requirement:
Internet Speed: Preferably above 1 MBPS
Headset: Any decent headset and microphone which can be used to 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.
For more information, you can reach out to the below contact:
Toll-Free No: 1-302-444-0162
Email: [email protected]