Review for medical necessity of admission against criteria

Slides:

Advertisements

Similar presentations

Getting it Right the First Time: Documentation of Medical Necessity for Short Stay Patients Steve Lokensgard Special Counsel Faegre & Benson David Orbuch.

Advertisements

Principles of Management System Auditing Managing the Internal Audit Program Planning the Internal Audit Conducting the Internal Audit Reporting the Audit.

The National Medicare RAC Summit “The Basics of Preparing for and Responding to RAC Demands” March 5, 2009 Presenter: Kathy Skrzypczak Assistant Vice President,

Clinical Documentation Improvement (CDI)

* HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse.

2 Midnight “New” Rule By Rebecca Corzine Tarr RN, CPA Executive Vice President MedPerformance LLC.

Ronald H Kilmer, RN, Ret.. "Medicare won't pay if we charge them for observing you, because it's not a medical necessity.."

5/11/20151 ALL YOU EVER WANTED TO KNOW ABOUT BILLING & REIMBURSEMENT BUT WERE AFRAID TO ASK Presented by: Evelyn Alwine, RHIA CHDA Director Revenue Cycle.

Overview Clinical Documentation & Revenue Management: Capturing the Services Prepared and Presented by Linda Hagen and Mae Regalado.

Optimization of ED Disposition Processes Jeff Wajda DO,MS, FACEP LYNX Medical Systems – a Picis Company January 27, 2008.

Denials Management. Objectives To understand the types of denials. Describe the Appeal Process. Learn Denial Prevention strategies. Differentiate between.

New York - Presbyterian Hospital RAC Lessons Learned Medicare’s Recovery Audit Contractor (RAC) Program Presented by Karen M. Feeley New York - Presbyterian.

PwC and Medical Necessity Issues and Concerns Emerging OIG scrutiny on medical necessity; nearly 500 hospitals on national target list for Medicare compliance.

Sacred Encounters Perfect Care Healthiest Communities New CMS FY 14 IPPS Rule affecting Inpatient Status What does the physician need to know.

The RACs Attack! Recovery Auditors and Critical Access Hospitals.

RAC Audits – A cautionary tale. Laura Zehm, Vice President & CFO, Community Hospital of the Monterey Peninsula.

Medicare Recovery Audit Contractor (RAC) Program Jennifer Amann, MBA Healthcare Resource Providers, LLC.

Clinical Documentation. Objectives Upon completion of this presentation participants will be able to: Define Clinical Documentation State the purpose.

ICD-10 IMPLEMENTATION – ARE YOU WHERE YOU NEED TO BE? Maureen Doherty, CPC, CPC-H EisnerAmper Healthcare Services Group June 2012.

Medicaid Hospital Utilization Review and DRG Audits: Frequently Asked Questions The Department of Medical Assistance Services Division of Program Integrity.

Hospital Claims UB-04 Revenue Cycle. Patient Access Patient Financial Services RCPSI Revenue Integrity HIM The billing process involves all areas of the.

RCMS (Revenue Cycle Management System) Flow chart model

Billing and Coding for Health Services

Medicare Advantage Audits

Not Another RAC Presentation! Presented By: Virginia Gleason, JD/MPA, CHC, CPHRM MHIMA 2011 Spring Meeting.

RACs, MACs, ZPICs, CMS, DOJ Are They Ever Going to Leave us Alone?

Hometown Health Sustaining a Financially Healthy Critical Access Hospital June 15, 2015.

Recovery Audit Contractor Program The Demonstration Project Experience - California.

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain.

Medicare Recovery Audits (RAC) Presented by: Shannon McGee, Director Florida Hospital Patient Financial Services

Cash Management. Areas of Concern Billing Systems – Edits – Are they current – Does the hospital track non-covered Medical necessity Contractual.

RAC Legal Defenses Renee M. Jordan, Esq. Bacen & Jordan, P.A Stirling Road, Suite 206 Fort Lauderdale, FL (954) (800)

Observation Status Medicare Rules

Dig Into RAC Preparation: Use Data Mining as a Preparation Strategy March 2009 Confidential Work Product.

Home Town Health Denial Update August 12, Agenda Latest on Estimated Denials 2016 OPPS Proposed Rule MedPerformance iMAD 2.

ICD-10 What’s Ahead. What is it? A renovation of coding, requiring field size expansion, change to alphanumeric digits, and complete redefinition of code.

D. Only a Level 3 code requires a comprehensive ROS C. Both codes require high complexity decision making B. Level 2 codes require examination of only.

Unlocking the Potential CDI We Have the Key Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDIS, CCDS.

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

FINANCIAL IMPLICATIONS: PUSH FROM INPATIENT TO OUTPATIENT CARE

Hospital Billing Overview Access Training and Development Department.

CARE IMPROVEMENT - Attention: Participating Providers Effective April 20, 2015, Care Improvement Plus (CIP) will begin to perform a concurrent medical.

NATIONAL HEALTHCARE COMPLIANCE AUDIOCONFERENCE UPDATE ON CMS ROLLOUT OF MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) THE NEW YORK STATE EXPERIENCE October.

The Pre-Payment audit of applies to Florida First Coast Providers. Audits are usually picked up by other payers. Georgia Update.

Getting and Keeping Cash Prospering in the Setting of MS DRG’s and Recovery Audit Contractors Jim Hull –Hull Resource Management Group Raul Velazquez –Health.

Chief Financial Officer Director, Revenue Cycle

AUTOMATED WORKFLOW ELECTRONIC SIGNATURE CAPTURE PRINT MANAGEMENT OHIMA’12 Booth 33 Theresa Wilton.

Caroline Rader, Associate Director Navigant Consulting, Inc. Outpatient CDI: The New Frontier?

What is Clinical Documentation Integrity?

Denial Prevention – Best Practice

Denial Strategies for Dealing with Ohio Payers

DRG Denials, Medical Necessity and Payer Behaviors

CHAPTER 6 ACCOUNTS RECEIVABLE (A/R) MANAGEMENT

Tracey A. Tomak, RHIA Director of Clinical Denial Prevention

ASSIGNMENT NO.-2.

Fundamentals of Denials Management

Billing and Coding for Health Services

Document information 3.02 Understand Health Informatics

برنامه‌ريزي منابع انساني

OUT-PATIENT IN A BED (OIB) PROCESS.

ICD-10 Updates.

APR DRG’S & CLINICAL VALIDATION

Medicare Recovery Audits (RAC)

Vladimir Zelensky Director, Moscow State Health Insurance Fund

Document information 3.02 Understand Health Informatics

Retrospective Post Payment Claim Review 2019 Q1

Document information 3.02 Understand Health Informatics

Document information 3.02 Understand Health Informatics

Retrospective Post Payment Claim Review 2019 Q2

Presentation transcript:

Review for medical necessity of admission against criteria Inpatient claim flow Concurrent review by CDI/coder; “working DRG” Service ordered/ provided/ documented Chargemaster Query to and from physician for increased specificity Organization appeals or writes off Coding/DRG assigned Billing/claim scrub/sync up with payer requirements Claim dropped to payer Payer pays/denies all or part of claim Post-payment audit (RAC, MIC, etc.)

Service ordered/ provided/documented Outpatient claim flow Service ordered/ provided/documented Chargemaster Query to and from physician for increased specificity Organization appeals or writes off Coding/DRG assigned Billing/claim scrub/sync up with payer requirements Claim dropped to payer Payer pays/denies all or part of claim Post-payment audit (RAC, MIC, etc.)