Medicare Boot Camp®—Utilization Review for Critical Access Hospitals

Course Overview

The Medicare Boot Camp®—Utilization Review for Critical Access Hospitals is an intensive course focusing on the Medicare regulatory requirements for patient status and the role of the utilization review (UR) committee. This is the only course of its kind catered exclusively to the needs of critical access hospitals (CAH).

CAHs have a unique set of issues related to UR, including the complexities of swing bed admissions. CMS has directed Medicare Advantage plans to follow the fee-for-service Medicare UR rules, and CAHs must be prepared to ensure plans understand the CAH environment and are compliant with inpatient admissions and observation stays. Don’t become a target or leave money on the table—have confidence in the UR determinations you and your facility are making.

The Medicare Boot Camp—Utilization Review for Critical Access Hospitals 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
• How the inpatient-only provisions apply to CAH services
• CMS guidance on case-by-case admissions
• The observation coverage rules and how they interact with the 2-midnight benchmark
• Rules for inpatient admission determinations by Medicare Advantage plans
• 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) and local coverage determinations (LCD) affect coverage of cases that meet the 2-midnight benchmark
• When the Advance Beneficiary Notice (ABN) and Hospital-Issued Notice of Non-Coverage (HINN) should be used for stays that don’t meet medical necessity requirements
• Requirements for swing bed coverage

This Boot Camp will help you to:

• Determine the correct inpatient or outpatient status of a patient under Medicare guidelines
• Conduct compliant UR 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 compliance and accurate reimbursement

Who should attend?
With a more clinical focus than HCPro’s other Boot Camps, this class is designed for the physicians and nurses involved in the Medicare UR process, as well as the revenue cycle Product/ Lead Instructor professionals 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.
• 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.

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®—Utilization Review for Critical Access Hospitals

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, including guidelines for evaluating medical necessity
• Medicare Coverage Center, including local coverage determinations (LCD), national coverage determinations (NCD), and Coverage with Evidence Development (CED)
• Medicare Advantage plan coverage determinations, including prior authorizations

Module 3: Coverage of Observation

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

Module 4: Medicare Outpatient Notices

• The Medicare Outpatient Observation Notice (MOON)
• 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: Coverage, Notices, and Billing for Swing Bed Admissions in a CAH

• Coverage for swing beds
• Level of care and documentation requirements
• Skilled nursing facility (SNF) ABN notice requirement
• Reimbursement methodology and patient coinsurance
• Consolidated billing rules for CAH swing beds

Course agenda/outline is subject to change.

Medicare Boot Camp®—Utilization Review for Critical Access Hospitals

Learning Objectives

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

• Apply Medicare observation coverage rules
• Evaluate the appropriate application of ABNs for observation patients
• Comply with inpatient order and certification requirements
• Break down the 2-midnight benchmark
• Identify exceptions to the 2-midnight benchmark
• Assess the effect of the inpatient-only list on UR determinations
• Differentiate between condition codes 44 and W2
• Quantify inpatient and outpatient deductibles and copayments

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 Improvement 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 for Critical Access Hospitals

Things to Know Before Attending Class

What Is Included With Your Purchase

When you purchase a seat for our live virtual Boot Camps, you get online access for one participant to the live sessions, a hard copy of our printed workbook materials, and access to the recordings of the sessions. HCPro reserves the right to revoke your access if we find that you are sharing your login or any of the class information.

Course Materials

You will receive a hard copy of the class materials. These will be shipped to you via UPS. If ordering on our website, please be sure to enter the physical address where these materials should be shipped to. If you order over the phone or are unsure of what address we have on file, please ask the person you are speaking with to verify your address information or call our customer service department. Materials should arrive approximately two business days prior to the start of class.

Virtual Boot Camp Platform

We use GoToMeeting to present our virtual Boot Camps. To ensure your system supports GoToMeeting, visit https://support.goto.com/meeting/system-check. We will send out access information for the class four business days prior to the class start date and again one business day prior.

Session Recordings

You will have access to the recordings of each class session via a password protected page on our website. You will be given the page location two business days following the first session. Recordings will be added to the page within one business day following the live session. You will have access to this page for 60 days after the final live session.

Continuing Education Credits

To receive continuing education credits, you will be required to successfully complete a 40-question quiz based on the content covered throughout the course. Successful completion is achieved by getting at least 80% of the multiple-choice questions correct.

What to Bring to Class

We suggest that you have the following available during the class: 

• Highlighter
• Notepaper
• Sticky notes/flags
• Pen/pencil

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 for Critical Access Hospitals

Questions/Answers

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 suggest that you have the following available during the class:

• Highlighter
• Notepaper
• Sticky notes/flags
• Pen/pencil

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

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