Medicare Boot Camp®—Healthcare Claims Audits, Denials and Appeals Version

Course Overview

Reduce claim denials and win appeals

With the evolution of reimbursement models, healthcare legislation, and CMS policies, organizations cannot afford to write off appealable denials. The Medicare Boot Camp®—Healthcare Claims Audits, Denials and Appeals Version provides an in-depth look at denials management and appeal processes. In addition, this Boot Camp teaches you how to develop a meaningful claims audit process from beginning to end, incorporating official guidance and regulations needed for an effective compliance program. You’ll leave this class armed with a thorough understanding of these processes, ready to translate your new knowledge into tangible results.

You will leave this program knowing how to:

• Prepare for CMS audits
• Implement policies to identify disputable denials and support appeals
• Navigate the appeal process up through and beyond the Administrative Law Judge level
• Research upcoming audit focus areas
• Assess areas of risk within your organization
• Develop an effective risk-based audit process

You will leave this Boot Camp with an understanding of:

• The audit, denial, and appeal processes
• How to comply with regulations and CMS policies to increase reimbursement from the get-go
• How to increase your organization’s favorable appeal decisions
• The framework of conducting a claims audit
• The risk-based audit approach

Who should attend?

• The course is fit for any member of your billing, revenue, or clinical team who wants to learn more about navigating appeals, denials, or audits, including:
• Revenue cycle directors and managers
• Revenue integrity directors, managers, and staff
• HIM directors, managers, and staff
• CDI directors, managers, and specialists
• Compliance directors, officers, and auditors
• Business office managers
• Case management directors and managers
• Case managers
• Utilization review staff
• Utilization management staff
• Physician advisors
• Audit directors and coordinators
• Auditors
• Appeal coordinators
• Patient financial services directors

Want to attend only the Denials and Appeals, or only the Healthcare Claims Audit? You can! Make your selection of class preference at the top of this page—take the individual class that is most relevant to you, or take the combined class! For more information, visit these individual pages:

Medicare Boot Camp®—Denials and Appeals Version
Medicare Boot Camp®—Healthcare Claims Audit Version

See the HCPro difference for yourself!

Focus on the actual rules: Learn how to find and apply CMS rules and guidelines to ensure hospital services furnished to Medicare beneficiaries are billed accurately and appropriately.

Tools and skills to navigate Medicare rules: Our instructors provide valuable tools and resources that will help you prioritize and research Medicare questions long after the Boot Camp ends.

Applied learning: Case studies throughout each module ensure participants understand the concepts and know how to apply them to real-world situations.

Small class size: A low participant-to-teacher ratio is guaranteed.

Highly rated, well-established program: Participants consistently give the course an overall rating of 4.75 or higher (on a 5.0 scale).

For more detailed information about our Boot Camps, contact us at 800-650-6787 or email sales@hcpro.com.

Looking to train your whole team? We can bring our expert instructors to you! Learn more here!

Medicare Boot Camp®—Healthcare Claims Audits, Denials and Appeals Version

Agenda

Module 1: Audit Framework Overview and Resources

• Compliance plan
• Internal policies and procedures
• Scheduling
• Review and final sign-off
• Overall scope

Module 2: Sources of Authority

• Medicare & Medicaid manuals
• Provider manuals
• NCDs & LCDs
• Transmittals

Module 3: Assessing Areas of Risk

• OIG Work Plan
• CERT, RAC, TPE
• Comparative Billing Report
• Third-party audit requests
• Denial trends
• New services
• New and changed payment policies

Module 4: Risk-Based Audits

• Overall structure
• Benefits of risk-based audits
• Identifying unique risks to an organization
• PEPPER reports
• Targeting outliers

Module 5: Selecting an Audit Sample

• Identifying the purpose and objective
• Volume and dollar
• Payer type
• Identifying and determining what to omit
• Randomized versus statistical sample

Module 6: Managing Audit Details

• Organization
• Documentation
• Electronic versus paper files
• Understanding end deliverables
• Managing voluminous audits

Module 7: Drafting an Audit Report

• Executive summary
• Background
• Scope and objectives
• Sample methodology
• Error rate calculation 
• Regulatory criteria
• Detailed findings

Module 8: Audit Findings and Follow-Up

• Meaningful audit findings
• Communication of findings
• Ownership and action plan
• Education and training
• Follow-up process and when follow-up is necessary

Module 9: Remittance and Payer Communication

• Understanding how to read a remittance/EOB
• Knowing the meaning of remittance/EOB terms
• Different payer communications
• Remittance Advice Remark Codes

Module 10: Denials and Appeals Overview

• Understanding the types of denials
• Steps involved when handling denials
• The main structure of appeals
• Timeline associated with appeals

Module 11: Medicare Overview and Contractors

• The four parts of Medicare
• Medicare contractors
• Independent government agencies—Medicare involvement

Module 12: Medicare, Medicaid, and Commercial Research and Resources

• Web-based resources
• Key sources of authority
• Medicare Coverage Center, including LCDs, NCDs, CED, and Lab Coverage Manual
• Medicaid manual research
• Commercial payer research
• Common contractual language in commercial contracts
• Ways to stay current

Module 13: Claims Review and Audits Overview

• Overview of claim review program
• Types of claim reviews
• Review authorities
• Claim review process requirements

Module 14: Prepayment Claim Reviews/Audits

• Overview of prepayment reviews
• Automated prepayment reviews
• Prepayment non-medical record reviews
• Prepayment medical record reviews

Module 15: Postpayment Claim Reviews/Audits

• Establishment of postpayment claim review/audits process
• Postpayment claim reviews/audits overview
• Postpayment non-medical record reviews
• Statistical sampling and extrapolations
• Postpayment medical record reviews

Module 16: Medicare FFS Claim Appeal Process

• Initial determinations
• Reopenings and overlap with appeals process
• Level 1 appeal process: Redetermination
• Level 2 appeal process: Reconsideration
• Level 3 appeal process: Administrative Law Judge (ALJ) hearing
• Level 4 appeal process: Medicare Appeals Council
• Level 5 appeal process: Judicial review in U.S. district court

Module 17: Commercial Audit and Appeal Process

• Audit overview
• Appeals process
• Strategies for appeals
• Common appeal levels

Module 18: No Surprises Act Appeal Process

• Overview of the No Surprises Act
• Qualifying payment amount
• Good faith negotiation
• Arbitration

Module 19: Drafting and Constructing an Appeal Letter

• Overview of common elements of appeal letters
• Specific items to address in an appeal letter
• Structure of an effective appeal letter
• Identifying proper sources

Course agenda/outline is subject to change.

Medicare Boot Camp®—Healthcare Claims Audits, Denials and Appeals Version

Learning Objectives

At the conclusion of this educational activity, participants will be able to:

• Articulate the core elements of a properly designed claims audit 
• Develop risk-based claim audit areas 
• Develop a meaningful claims audit sample 
• Analyze claims and publicly available data to build an audit structure
• Interpret the appeal process and related regulations
• Define key steps in the appeal process up to the Administrative Law Judge level
• Design policies and practices to support compliance, reduce denials, and expedite appeals
• Examine denied claims to select appropriate appeals
• Equip denials and appeal staff with effective and efficient strategies to effectively review and respond to denials and appeals
• Conduct research necessary to respond and effectively draft an appeal
• Articulate the common commercial contractual clauses that impact audits and appeals
• Construct a solid appeal letter and the necessary components to include in appeal letters

Continuing Education

* Coming Soon! 

Medicare Boot Camp®—Healthcare Claims Audits, Denials and Appeals Version

Questions/ Answers

What is the focus of the Medicare Boot Camp®—Healthcare Claims Audits, Denials and Appeals Version?
The Medicare Boot Camp— Healthcare Claims Audits, Denials and Appeals Version is an intensive, three-day course on Medicare appeals and denials management, covering the Medicare claims review processes, types of audits and how providers should respond to them, and the different levels of the appeal process. The goal of the course is to provide participants with a sound understanding of the audit, denial, and appeal processes, including the payer perspective, based directly upon current regulations.

Where is the course offered?
Open registration sessions are offered at various locations around the country, typically at mid-priced business hotels such as HYATT Place or Hilton Garden Inn. For a current schedule of upcoming open registration courses, click on "Locations/Dates" above.

Does HCPro offer an on-site version of this Boot Camp?
In addition to our open registration courses, we also offer this Boot Camp as an on-site program (with a substantial discount) for organizations that have a number of employees who need training. For more information on hosting an on-site Boot Camp, click on Host an On-Site Course.

What if I need to cancel or transfer my registration?
To view our cancellation policy, click here.

Who typically attends the Medicare Boot Camp—Healthcare Claims Audits, Denials and Appeals Version?

• Revenue cycle directors and managers
• Revenue integrity directors, managers, and staff
• HIM directors, managers, and staff
• CDI directors, managers, and specialists
• Compliance directors, officers, and auditors
• Business office managers
• Case management directors and managers
• Case managers
• Utilization review staff
• Utilization management staff
• Physician advisors
• Audit directors and coordinators
• Auditors
• Appeal coordinators
• Patient financial services directors

What material does the course cover?
To view the course outline, click on "Course Outline" above.

Does the course require any previous experience or training?
No. The course starts with Medicare fundamentals and does not assume that participants have any particular background or experience. However, because of the fast-paced nature of the course, it is recommended (but not required) that participants have at least one year of experience working in a hospital.

How is the course taught?
The course is taught using a combination of lecture, class discussion, and hands-on exercise/case studies.

What do I need to bring to class?
When you arrive at class, you will receive an extensive notebook of course materials. In addition, please bring the following to all classes:

• A highlighter
• A notebook for taking notes
• Sticky notes/flags
• A pen/pencil

Does HCPro ever share contact information (e.g., name, address, phone number, email address, etc.) with other companies?
Historically, we have not shared contact information with anyone outside of our company. However, it is possible that at some point we might share contact information with other companies that offer products and services that we think would be of interest to our customers. If you would like us to keep your contact information confidential, please let us know so that we can flag your information in our customer database as "Do Not Share."

How do I get more information? 
Contact us at 800-650-6787 or email a href="mailto:sales@hcpro.com">sales@hcpro.com.

Medicare Boot Camp®—Healthcare Claims Audits, Denials and Appeals Version

Things to Know Before Attending Class

Directions and Hotel Information

The hotel address, phone number, URL, room rate and room rate cut-off date are posted on our website at https://hcmarketplace.com/product-type/boot-camps/medicare. The hotel websites give detailed directions to the hotel as well as information about the location. Please call the hotel directly to make a room reservation. Be sure to identify yourself as an HCPro Boot Camp participant. Please be sure to make your reservation before the cut-off date. After the cut-off date, contact the hotel to determine room availability and rates.

Course Materials

When you arrive at class, you will receive extensive workbooks containing the class materials utilized throughout the Boot Camp. The workbooks will be yours to keep, so plan accordingly in allowing enough room in your luggage on the return trip home. Workbooks may also be shipped from the hotel at your own expense.  

Classroom Time

It is an understatement to say that this course is intense. Other than breaks, we will be in class from 8:00 a.m. to 5:00 p.m. each day. If the class gets behind, class may run later than 5:00 p.m.

Lunch

Although we typically provide coffee in the morning and drinks and snacks in the afternoon, everyone is on their own for lunch. Note that many hotels do not have restaurants on-site. If you are flying to the course, we generally recommend renting a car.

What to Bring to Class

We recommend you bring the following to all classes:

• Highlighter and pen/pencil
• A notebook for making your own notes
• Sticky notes/flags 

Use of Laptop Computers or Electronic Devices

Our instructors demonstrate where to find many resources on the CMS website. If you have access to a laptop or tablet, you may bring it to class to follow along, but you may wish to consider the power and wireless needs of your device. Many conference rooms do not have plugins situated conveniently to the tables, so you may wish to ensure you have sufficient battery power. HCPro does not purchase group wireless access for the conference rooms, but many hotels provide free wireless access. You may wish to confirm your connectivity options prior to arriving at the hotel. Please be courteous in your use of electronic devices. Use of electronic devices should not disrupt the class or disturb other participants. HCPro is not responsible for lost, stolen, or damaged devices. Maintaining the security and safety of your device is your responsibility. Cell phone use during class is strictly prohibited.

Dress

Business attire is not necessary. Please dress comfortably. Also, we find that the classrooms are sometimes on the cool side, even during the warmer months. You may be more comfortable if you bring a sweater or sweatshirt in case you get cold.

Copyright Protection of Course Materials

You will receive a complete copy of our course materials at the beginning of class. The materials used were custom designed by our company specifically for use in connection with this course. We have invested a tremendous amount of time, money, and effort in developing, refining, and maintaining these materials, and they are protected by copyright laws. Course materials may not be duplicated. You may use the materials in direct connection with the course or (ii) as a personal reference in your day-to-day work. No claim is asserted to any U.S. Government, American Medical Association, or American Hospital Association works included in the course materials workbook.

Cancellation and Transfer Policy

For our cancellation and transfer policy, visit our website: http://hcmarketplace.com/cancellations

Contact Information

If you have any question about the Boot Camp program, please contact: 

Customer Service
(800) 650-6787 phone 
(800) 785-9212 fax
https://hcmarketplace.com/product-type/boot-camps

We Look Forward to Having You In Class!