Medicare Boot Camp®—Utilization Review Version

Course Overview

Master Medicare rules for utilization review

Medicare Boot Camp®—Utilization Review Version is an intensive two-day course focusing on the Medicare regulatory requirements for patient status and the role of the utilization review (UR) committee.

UR processes play an important role in the revenue cycle and maintaining compliance. CMS has directed Medicare Advantage plans to follow the fee-for-service Medicare UR rules, and hospitals must be prepared to ensure plans are compliant in authorizing inpatient stays and observation. CMS contractor Livanta also continues to audit short stays. Don't become a target or leave money on the table—have confidence in the UR determinations you and your facility are making.

Medicare Boot Camp—Utilization Review Version also answers all your questions about navigating the CMS website and finding Medicare resources.

You will leave this program knowing:

• How to apply the 2-midnight benchmark 
• The observation coverage rules and how they interact with the 2-midnight benchmark 
• How to find and apply the Medicare inpatient -only list 
• CMS guidance on case-by-case admissions 
• Rules for inpatient admission determinations by Medicare Advantage Pplans 
• The differences between post-discharge and concurrent patient status reviews 
• When self-denial is appropriate to take advantage of Part B payment for an inpatient case 
• How national coverage determinations (NCD), local coverage determinations (LCD), and Coverage with Evidence Development (CED) affect coverage of cases that meet the 2-midnight benchmark 
• When and how Medicare Advantage plans must comply with coverage policies or can deviate from them 
• When the Advance Beneficiary Notice (ABN) and the Hospital-Issued Notice of Non-Coverage (HINN) should be used for stays that don't meet medical necessity requirements 
• Delivery requirements for the Important Message from Medicare (IM) and the Detailed Notice of Discharge (DN)

This Boot Camp will help you to:

• Determine the correct inpatient or outpatient status of a patient under Medicare guidelines
• Conduct compliant reviews of a Medicare patient's status
• Implement condition code 44 or self-denial processes correctly and compliantly
• Understand the role of a UR team in your organization and how they contribute to compliant and accurate reimbursement

Who should attend?
With a more clinical focus than other Boot Camp courses, this class is designed for the physicians and nurses involved in the Medicare UR process, as well as the revenue cycle staff who support them. The course is also helpful for staff dealing with inpatient and outpatient denials and appeals. 

• UR coordinators
• UR managers and directors
• UR committee members
• UR physician advisors
• Case managers
• Care coordinators
• Revenue cycle staff
• Nurse managers
• Compliance officers and auditors
• Medicare Administrative Contractor (MAC) personnel
• Healthcare lawyers and consultants

See the HCPro difference for yourself!

• Focus on the actual rules: We provide references for all information provided and tools directly from Medicare, giving you confidence you are getting accurate, timely information.
• Tools and skills to navigate Medicare rules: Our instructors provide valuable understanding, tools, and resources to help you be more efficient applying Medicare guidelines.
• Case studies: Case studies ensure attendees 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 HCPro's Boot Camps, 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®—Utilization Review Version

Course Outline

Module 1: Medicare Program, Contractors, and Resources

• Overview of Medicare Part A, B, C, and D
• Medicare contractors, including Medicare Administrative Contractors (MAC), Recovery Audit Contractors (RAC), and Quality Improvement Organizations (QIO)
• Web-based resources and key sources of Medicare authority

Module 2: Medical Necessity Rules, Policies, and Notices

• Medicare Coverage Center, including local coverage determinations (LCD), national coverage determinations (NCD), and Coverage with Evidence Development (CED)
• Coverage of services related to clinical trials, registries, and studies
• Medicare Advantage plan coverage determinations, including prior authorizations
• Prior authorizations for specified outpatient procedures and services

Module 3: Coverage of Observation

• Coverage of observation services
• Coding and billing of observation
• Payment for observation, including at Prospective Payment System (PPS) hospitals and critical access hospitals (CAH)

Module 4: Medicare Outpatient Notices

• The Medicare Outpatient Observation Notice (MOON)
• The Advance Beneficiary Notice (ABN) for non-covered observation

Module 5: Inpatient Orders and Certification

• Inpatient order requirements
• Inpatient certification requirements, including 96-hour CAH certification

Module 6: Inpatient Admission Guidelines

• Inpatient-only procedures
• The 2-midnight benchmark
• Admission on a case-by-case basis
• Livanta guidance, including clinical examples 

Module 7: Inpatient Utilization Review (UR) and Billing Requirements

• UR requirements and self-denials
• Concurrent review and billing with condition code 44
• Inpatient Part B payment and billing with condition code W2

Module 8: Medicare Inpatient Notices

• Important Message from Medicare (IM)
• Detailed Notice of Discharge (DN)
• Hospital-Issued Notice of Non-Coverage (HINN) for non-covered inpatient services

Module 9: Overview of Inpatient Payment Systems and Patient Liability

• Basics of the Inpatient Prospective Payment System (IPPS)
• Three-day payment window and preadmission services
• Medicare Severity Diagnosis-Related Groups (MS-DRG)
• Payment for transfers and post-acute care transfers
• Inpatient deductible, coinsurance, and lifetime reserve days (LRD)

Module 10: Outpatient Payment Systems and Patient Liability

• Basics of the Outpatient Prospective Payment System (OPPS)
• Encounter-based Comprehensive Ambulatory Payment Classifications (C-APC)
• Patient coinsurance under Part B

Course Outline/Agenda subject to change.

Medicare Boot Camp®—Utilization Review Version

Learning Objectives

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

• Define observation coverage, billing, coding, and payment rules
• Discuss the appropriate application of ABNs for observation patients
• State the inpatient order and certification requirements
• Explain CMS’ 2-midnight rule benchmark 
• Recognize exceptions to the 2-midnight benchmark
• Describe the impact of LCD/NCD/CED criteria on inpatient coverage
• State the rules for "inpatient-only" procedure billing and reimbursement
• Describe the differences between condition codes 44 and W2
• Use appropriate billing codes for full Part B payment for inpatient cases, including for "self-denials"
• Differentiate inpatient and outpatient deductibles and co-payments

Continuing Education

ACCME
HCPro is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

HCPro designates this educational activity for a maximum of 15 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

ACDIS
This program has been approved for 15 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).

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 15 nursing contact hours.

CCMC
This program has been pre-approved by the Commission for Case Manager Certification to provide 15 continuing education credit to Certified Case Managers (CCMs).

NAHRI
This program has been approved for 15 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®—Utilization Review 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 the Locations/Dates tab. 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 an extensive workbook containing the class materials utilized throughout the boot camp. This workbook 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 8:00am to 5:00pm daily. There will be about a one hour lunch break each day. If the class gets behind, class may run later than 5:00pm.  

Lunch

We will take about a one hour break for lunch each day. 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
• Calculator

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 in connection with this course 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 (i) 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

COVID Safety

Simplify Compliance and HCPro place the highest priority on the safety of our guests. In preparation for attendance at our events, we want to share the following measures to promote health and well-being:

• If the region where our event is located is deemed by the CDC to be within the substantial or high-risk category, we will require all attendees, regardless of vaccination status, to wear masks when indoors except while actively eating or drinking. 
• Meeting rooms will be set to support social distancing when necessary.
• Food service will follow the safety guidelines implemented by the hotel.

To view all the safety measures that a specific hotel has implemented, please see the information listed on their website.

Simplify Compliance and HCPro will continue to monitor the COVID-19 environment and the recommended guidelines, and will communicate adjustments to the onsite policies and procedures as necessary.

Contact Information

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

We Look Forward to Having You In Class!

Medicare Boot Camp®—Utilization Review Version

Questions/Answers

What is the focus of the Medicare Boot Camp®—Utilization Review Version?
Medicare Boot Camp—Utilization Review Version is an intensive two-day course focusing on the Medicare regulatory requirements for patient status and the role of the utilization review (UR) committee.

Where is the course offered?
Open registration sessions of Medicare Boot Camp—Utilization Review Version 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 Medicare Boot Camps, click on "Locations/Dates."

Does HCPro offer on-site sessions of Medicare Boot Camp—Utilization Review Version?
In addition to our open registration courses, we also offer Medicare Boot Camp—Utilization Review Version as an on-site program (with a substantial discount) for organizations with a number of employees who need training. For more information on hosting an on-site Medicare Boot Camp—Utilization Review Version, click on Train Groups On-site.

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

Who typically attends Medicare Boot Camp—Utilization Review Version?

• UR coordinators
• UR managers and directors
• UR committee members
• UR physician advisors
• Case managers
• Care coordinators
• Revenue cycle staff
• Nurse managers
• Compliance officers and auditors
• Medicare Administrative Contractor (MAC) personnel
• Healthcare lawyers and consultants

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.

How is the course taught?
The course is taught using a combination of lecture, class discussion, and 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, you may wish to bring the following to all classes:

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

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.