Boot Camps

Live Virtual Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit

Course Overview

Develop a strategic risk-based audit process, 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. Live Virtual Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit  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 appeals 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 appeals processes
• How to comply with regulations and CMS policies to increase reimbursement from the get-go
• How to increase your organizations 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
• Utilizations review staff
• Utilization management staff
• Physician advisors
• Audit directors and coordinators
• Auditors
• Appeals coordinators
• Patient financial services directors
  
  

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).

How does the Live Virtual Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit work?

Class is held Monday – Wednesday for 1 week from 11:00 p.m. – 5:00 p.m. Eastern Time (3 classes).

Please Note: Four days before class starts, you will receive a welcome email that includes the dial-in information for the class.

Monday – Friday from April 29 – May 3. Registration cut-off date: 4/22/2024

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!

Live Virtual Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit

Outline/Agenda

Day 1 & 2

Overall Learning Objectives:

• Equip denials and appeal staff with effective and efficient strategies to effectively review and respond to denials and appeals.
• Gain a working understanding of the Medicare appeals levels.
• Gain a working understanding of Commercial appeals processes and strategies.
• Understand various areas of research necessary to respond and effectively draft an appeal.
• Gain an understanding of common commercial contractual clauses that impact audits and appeals.
• Gain a solid understanding how to construct a solid appeal letter and the necessary components to include in appeal letters.

Module 1: Denials and Appeals Overview

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

Module 2: Medicare Overview and Contractors

• The Four Parts of Medicare
• Medicare Contractors
• Independent Government Agencies-Medicare Involvement

Module 3: 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 Payor Research
• Common Contractual Language in Commercial Contracts
• Ways to Stay Current

Module 4: Prepayment Claim Reviews/Audits

• Prepayment Reviews Overview
• Automated Prepayment Reviews
• Prepayment Non-Medical Record Reviews
• Prepayment Medical Record Reviews

Module 5: 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 6: Medicare FFS Claim Appeals 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 7: Commercial Audit and Appeals Process

• Audit Overview
• Appeals Process
• Strategies for Appeals
• Common appeal levels

Module 8: No Surprises Act Appeal Process

• Overview of the No Surprises Act
• Qualifying Payment Amount
• Good faith negotiation
• Arbitration

Module 9: Drafting and Constructing an Appeal Letter

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

Day 3
Overall Learning Objectives

• Understand the overall framework of conducting a claims audit
• Learn various steps needed based on the type of claims audit
• Understand how to examine and determine risk areas
• Learn how to pull a relevant audit sample and different methods for doing so
• Learn how to draft a comprehensive and meaningful audit report

Module 1: Audit Framework Overview and Resources

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

Module 2: Sources of Authority

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

Module 3: Assessing Areas of Risk

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

Module 4: Risk-Based Audits

• Overall structure
• Benefits
• Identifying unique risks to an organization
• PEPPER reports
• Targeting outliers

Module 5: Selecting an Audit Sample

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

Module 6: Managing Audit Details

• Organization structure and impact
• Required documentation
• Electronic versus paper files
• 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 necessity

Module 9: Remittance and Payer Communication

• How to read a remittance/EOB
• Meanings of remittance/EOB terms
• Different payer communications
• Remittance Advice Remark Codes

Course Agenda/Outline is subject to change.

Live Virtual Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit

Schedule

October — Class Schedule (Eastern time)

Live Virtual Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit

Questions/ Answers

What is the focus of the Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit Version?
The Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit 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 appeals 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®— Denials and Appeals & Healthcare Claims Audit 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
• Utilizations review staff
• Utilization management staff
• Physician advisors
• Audit directors and coordinators
• Auditors
• Appeals 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

Live Virtual Medicare Boot Camp®—Denials and Appeals & Healthcare Claims Audit

Learning Objectives

*Coming Soon!

Continuing Education

* Coming Soon!