This site uses cookies in order to give you the best experience.
We and our third-party partners may use cookies and similar technologies,
for example, to analyze usage and optimize our sites and services, personalize content,
tailor and measure our marketing and to keep the site secure.
Please visit our privacy policy for more information.
Privacy Policy
Medicare Boot Camp®—Healthcare Claims Audits, Denials and Appeals Version
Product Code:
MDBC
The Medicare Boot Camp®—Healthcare Claims Audits, Denials and Appeals Version is an intensive course covering the Medicare claims review processes, audits and responses, and the different levels of the appeal process.
This in-person Boot Camp is best for those looking for an interactive learning experience. Classes led by our expert instructors take place over the course of a week and allow instructor/student interaction, engagement, and networking with peers. |
Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit
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
See the HCPro difference for yourself!
- Focus on the actual rules: You’ll learn how to prepare for CMS audits and navigate the appeals process, and gain familiarity with the rules and regulations up through (and beyond) the Administrative Law Judge and the Medicare Appeals Council levels.
- Tools and skills to navigate Medicare rules: Our instructors provide valuable tools and resources that will help you prioritize and research time-sensitive issues long after the Boot Camp ends.
- 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 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
Course Outline
Module 1: Audit Framework Overview and Resources
- Compliance plan
- Internal policies and procedures
- Scheduling
- Review and final signoff
- Overall scope
Module 2: Sources of Authority
- Medicare and Medicaid manuals
- Provider manuals
- National and local coverage determinations (NCD, LCD)
- Transmittals
Module 3: Assessing Areas of Risk
- OIG Work Plan
- Comprehensive Error Rate Testing, Recovery Audit Contractors, and Targeted Probe and Educate (CERT, RAC, TPE)
- Comparative Billing Report (CBR)
- 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
- The Program for Evaluating Payment Patterns Electronic Report (PEPPER)
- 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 samples
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
- How to read a remittance/explanation of benefits (EOB)
- Meanings of remittance/EOB terms
- Various payer communications
- Remittance Advice Remark Codes (RARC)
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, Coverage with Evidence Development, 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 claims review program
- Types of claim reviews
- Review authorities
- Claims review process requirements
Module 14: Prepayment Claim Reviews/Audits
- Overview of prepayment reviews
- Automated prepayment reviews
- Prepayment nonmedical record reviews
- Prepayment medical record reviews
Module 15: Postpayment Claim Reviews/Audits
- Establishment of postpayment claims review/audit process
- Postpayment claim reviews/audits overview
- Postpayment nonmedical record reviews
- Statistical sampling and extrapolations
- Postpayment medical record reviews
Module 16: Medicare Fee-for-Service (FFS) Claim Appeal Process
- Initial determinations
- Reopenings and overlap with appeal 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
- Appeal 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
AAPC
This program has been approved by the AAPC for 22.5 continuing education hours. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.
ACDIS
This program has been approved for 22.5 continuing education units towards fulfilling the requirements of the Certified Clinical Documentation Specialist (CCDS) certification, offered as a service of the Association of Clinical Documentation Integrity Specialists (ACDIS).
AHIMA
This program has been approved for 22.5 continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.
ANCC
HCPro is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.
This activity is available for 22.5 nursing contact hours.
CCB
The Compliance Certification Board (CCB) has approved this event for up to 27 CCB CEUs. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this program content or of the program sponsor.
CCMC
This program has been pre-approved by The Commission for Case Manager Certification to provide 22.5 hours of continuing education credit to CCM board certified case managers.
NAHRI
This program has been approved for 22.5 continuing education units towards fulfilling the requirements of the Certification in Healthcare Revenue Integrity (CHRI), offered as a service of the National Association of Healthcare Revenue Integrity (NAHRI).
Disclosure Statement:
HCPro has confirmed that none of the faculty/presenters, planners, or contributors have any relevant financial relationships to disclose related to the content of this educational activity.
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: https://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!
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 sales@hcpro.com.