Product Detail

• Explain current billing and reimbursement issues
• Analyze how to make the claims process more efficient
• Accurately define and summarize medical necessity
• Assess Evaluation and Management Services Documentation principles
• Recognize how federal agencies audit
• Apply current knowledge of billing and coding tools to reduce delays, denials, and rejections
• Evaluate the appeals and self-auditing process
• Formulate a compliance plan for auditing

BILLING & CODING TOOLS

• Understanding the billing process and billing terminology
• Current reference materials
• Written policies and procedures covering billing protocol from insurance contractors
• ICD-9-CM diagnosis coding expertise (ICD-10 as of 10/1/2014)
• Well-designed patient information form or EMR (patient demographics)
• Understanding the insurance claims process
• Understanding the Health Insurance Portability and Accountability Act (HIPAA) and how it relates to claims processing

 

WHAT PAYERS WANT: DOCUMENTATION PRINCIPLES & MEDICAL NECESSITY

• The site of service
• Medical necessity and appropriateness of the diagnostic
• Therapeutic services provided
• Information that the services provided have been accurately reported

 

REVALUATING EVALUATION & MANAGEMENT CODING

• What are the elements of an evaluation and management code
• Getting paid for what you do

 

CLAIMS APPEALS: A KEY TO REIMBURSEMENT

• Implementing processes for appeals
• Determining an auditing staff
• Collection reports in determining appeals
• Appeals with EMR
• Understanding the explanation of benefits and remittance advice
• Proof of timely filing
• Developing an appeal letter

 

UNDERSTANDING FEDERAL AGENCIES THAT AUDIT

• Main governmental agencies auditing
• What is a CMS medical review?
• Components of a Medicare review
• Understanding national coverage determinations
• CERT, RAC, ZPIC, Medicaid Integrity Contractors
• Medicare Administrative Contractors

 

AUDITING MEDICAL RECORDS

• Medicare data banks
• Goals for an audit
• Types of audits
• DATA mining: predictive analysis
• CMS targets
• Documentation principles

 

DEFINING FRAUD & ABUSE

• False Claims Act
• Anti-Kickback Statutes
• Physician Self-Referral Law
• Medicare’s Fraud and Abuse Partnerships
• Office of Inspector General and HEAT program

 

WHAT IS MEDICAL NECESSITY?

• Medical necessity: the deciding factor in claims payment
• Medicare definition of medical necessity
• AMA definition of medical necessity
• Diagnoses frequently monitored for medical necessity

 

CREATING A COMPLIANCE PLAN

• OIG Guidelines
• Following the OIG work plan for auditing
• Compliance education
• Developing a compliance plan for your business office

 

PROPOSED CMS CHANGES FOR 2014

• OPPS payment changes
• IPPS payment changes

 

ICD-10: A PREVIEW

• Structure
• Principles of ICD-10
• Training for ICD-10
• Impact on ICD-10 in your IT departments
• Physician impact
• Character meaning

Biography is not currently avaiable.

Continuing Education Information
This educational offering is designed to qualify for continuing education for many professionals in every state.


Materials that are included in this course could include interventions and modalities that are beyond the authorized practice for your profession. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your professions standards.


Listed below are the continuing education credit(s) currently available for this educational offering. Please note, your state licensing board dictates what is an acceptable form of continuing education. Please refer to your state rules and regulations. If your profession is not listed, please contact your licensing board to determine your continuing education requirements and check for reciprocal approval. For other credit inquiries not specified below, please contact customerservice@vyne.com or 800-397-0180.


CE information is based on 100% attendance.

---

Other Professions
This educational offering qualifies for 6 continuing education hours as required by many national, state and local licensing boards and professional organizations. Save your course outline and certificate of completion, and contact your own board or organization for specific filing requirements.

• Billing, Insurance, and Coding Personnel
• Physician Office Managers
• Insurance Managers
• Business Managers
• Financial Managers
• Medical Assistants
• Medical Records Personnel