Revenue Integrity and Chargemaster Boot Camp

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1 *** LIMITED TIME OFFER: FREE $100 AMAZON GIFT CARD! *** REGISTER TODAY! Course Overview The provides education on chargemaster and revenue integrity concepts in a classroom format. The program will relate the chargemaster function to revenue cycle and revenue integrity functions, including cost reporting and key operational issues, such as coverage, clinical documentation, charge capture, and coding. It will also provide context for chargemaster set-up and maintenance within revenue integrity with an objective to help avoid pre- and post- billing edits and payer denials. You will leave this program knowing how to: Provide formal, organized education and training for revenue integrity and chargemaster staff Provide context for the intersection of the chargemaster with clinical/revenue departments, charge capture, coding, finance, and patient access and billing Walk attendees through CMS regulatory requirements for pricing and charging patients, as well as key relationships between the chargemaster and provider cost reporting Give detailed instructions for the majority of revenue codes for optimal chargemaster setup, maintenance, charge capture, and documentation issues Review chargemaster issues for commercial/managed care versus CMS requirements Learning Objectives At the conclusion of this educational activity, participants will be able to: Equip hospital, payer and other healthcare specialists with effective and efficient strategies to obtain and maintain overall revenue integrity for both governmental and non-governmental payers Gain a working understanding of revenue integrity principles associated with eligibility, coverage, coding, billing and payment using fee-for-service Medicare requirements as a framework Explain standard charge description master (CDM) elements, design and relationship to the general ledger and revenue cycle processes of coding and billing Review claim requirements and specific issues of CDM set-up and maintenance by revenue code with associated cost reporting principles Exemplify outpatient and inpatient hospital prospective payment systems reimbursement and rate setting methodologies as well as appeal strategies to protect revenue Outline/Agenda Module 1: Revenue Integrity Overview and Resources Revenue integrity functions and key principles including how the chargemaster fits into over revenue integrity functions Medicare and other revenue integrity and chargemaster resources Understanding authoritative sources such as statutes, regulations, manuals, transmittals and other Medicare rules and guidelines

2 Module 2: Eligibility Principles Review major and different types of medical insurances Principles of health insurance eligibility and verification of insurance Coordination of Benefits & Subrogation Medicare Secondary Payer (MSP) concepts Module 3: Benefits, Coverage and Medical Necessity Review how insurance benefits are structured for hospital and other services The importance of coverage, medical necessity and both implied and specifically excluded benefits Medicare s prohibition against unbundling for inpatient and outpatient hospital services Pre-service coverage analysis and associated waiver/notice requirements Serious preventable events and relationship to risk management Investigational/experimental services and implications for coverage Module 4: Provider Types, Licensure, Enrollment, & Privileges Types of facilities, providers, physicians, practitioners and suppliers Provider-based department requirements including implications of Section 603 of the Bipartisan Budget Act of 2015 Licensure, scope of practice, privileging and relationship to coverage Conditions of participation, survey & certification and accreditation Importance of medical staff bylaws & regulations and relationship to conditions of payment Exercises: Concepts of Revenue Integrity Module 5: Charge Description Master Structure and Charge Capture Principles Definition, purpose and key fields of a chargemaster Concepts for code set up in CDMs and relationship to HIM coding Principles of bundled services per CPT definition vs reporting packaged services and implications for separate charging of packaged services Strategies to address payer differences in the chargemaster The relationship of chargemaster to overall AR System Concepts for pricing services and why APCs are not a good gauge for pricing hospital services Chargemaster, general ledger and relationship to cost reporting Module 6: Claims Submission Fundamentals and Code Edits Key UB-04 fields applicable to hospital services HIPAA transaction sets including ICD-10 and HCPCS codes Common claim edits including NCCI and MUEs Other transaction sets applicable to the revenue cycle such as eligibility, payment, claim status and denial transaction sets Module 7: Special Medicare Billing Issues Billing requirements for outpatient repetitive versus non-repetitive recurring and nonrecurring services The three-day payment window and outpatient services billed on inpatient claims Billing of non-covered inpatient and outpatient services Patient status and billing inpatient non-medically necessary services Exercises: CDM Structure, Claims and Billing Issues Module 8: Strategies and Key Issues by Revenue Code: Routine Services and Observation Key concepts for accommodation codes and routine services, including outpatients in beds, specialty care units and observation services Coding and edit issues for revenue codes associated with routine services and observation

3 Module 9: Strategies and Key Issues by Revenue Code: Ancillary Services Key concepts for major ancillary service departments, including peri-operative services, emergency, cardiology, diagnostic imaging, pharmacy and supplies Coding and edit issues for revenue codes associated with ancillary services Module 10: Strategies and Key Issues by Revenue Code: Other Departments Key concepts for other common ancillary service departments, including respiratory therapy, clinics, behavioral health, and preventive services Coding and edit issues for revenue codes associated with other departments Exercises: Routine and Ancillary Services by Revenue Code Module 11: Introduction to Payment Systems Review inpatient payment systems including DRGs, APR-DRGs, Case Rates and Per Diems Discuss hospital outpatient hospital payment systems including OPPS & APCs, eapgs, fee schedules and percent of charges Review outpatient surgery payment methodologies such as ASC and ambulatory fee schedules Review other ambulatory service payment systems such as the physician fee schedule (MPFS), DMEPOS, Clinical Lab Fee Schedule Review emerging payment methodologies such as Bundled/Episode Payments (CJR) and Value-Based Purchasing Module 12: Outpatient Prospective Payment System (OPPS) Understanding OPPS payable services and structure of APCs Learn how to determine whether services are paid separately or packaged Understand C-APCs and complexity adjustments Understand impact of inpatient deductible cap on co-payments for beneficiaries Module 13: Medicare Physician Fee Schedule (MPFS) The resource-based relative value system Relative value unit (RVU) structure Site of service adjustments for facility and non-facility services Global versus technical and professional components Payment policy indicators Exercises: Payment Systems Module 14: Charge Description Master Management and Maintenance Strategies Issues surrounding the annual chargemaster updates including pricing, HCPCS codes, charge items with no volume Strategies to work collaboratively with departments Importance of patient account and charge reconciliation Tracking CDM changes for compliance Charge integrity monitoring and reducing unexplained variation in claims Module 15: Denial Management Principles of denial management Adjustment claims and automated provider reopening

4 Initial and revised determinations and appeal rights Levels of appeal and timelines for filing Types of auditors including external auditors from commercial plans Module 16: Payer Contracting Strategies Concept and criteria for carve out options Importance of tracking administrative cost by payer and developing and trending payer scorecards Contract negotiations and annual price increase limits/caps applicable to chargemaster Exercises: Strategies for CDM Management, Denials and Payer Contracting Course Outline/Agenda subject to change. Please contact the event manager Marilyn ) below for: - Multiple participant discounts - Price quotations or visa invitation letters - Payment by alternate channels (PayPal, check, Western Union, wire transfers etc) - Event sponsorships NO REFUNDS ALLOWED ON REGISTRATIONS Service fees included in this listing BUSINESS & LEGAL RESOURCES-BLR - New York Events List JOA190520CEV