Understanding Payer and Recovery Auditor Denial Tactics

Event Materials (Key Required)

Course Description

Hospitals are under ever-increasing financial pressures yet are expected to consistently achieve excellent patient care results. However, for several decades, the cost of providing care has only increased while hospital reimbursements have remained fairly flat. Therefore, maintaining financial solvency has become increasingly difficult for hospitals to continue their patient care missions. As the healthcare dollar shrinks for all parties involved, the frequency of hospital payment denials and previously obtained reimbursement recoupments has skyrocketed. Additionally, the administrative burden of appealing payer and recovery auditor denials has correspondingly increased further straining hospital resources. In this session, the most common initial payment denial and post-payment recoupment strategies utilized by CMS, its various contractors, and the commercial payers will be reviewed. Understanding how a payer or recovery auditor searches for and then issues any denial is the first step to developing an effective and coordinated denial prevention strategy. As denial prevention is infinitely cheaper and significantly easier than fighting through the cumbersome and lengthy appeals process, hospitals should focus more of their efforts on denial mitigation. This can only be undertaken with a thorough and in-depth understanding of the denial weapons deployed against your organization.

Learning Objectives

• Learn why your hospital is a denial target
• Learn the most utilized denial strategies deployed against hospitals to prevent and recoup reimbursements
• Understand how provider documentation is a critical factor for facilitating hospital denials and preventing future denials
• Understand how Observation vs. Inpatient status impacts hospital reimbursement and denial risk
• Identify why hospital status is a common target for payers and auditors
• Learn what MS-DRGs are and why certain MS-DRGs are frequently targeted for downgrades
• Understand how MS-DRG downgrades are carried out to recoup payments
• Define Medical Necessity and how it is used to justify denials and recoupments
• Learn how proper documentation can help prevent Medical Necessity denials
• Understand why proactive denial prevention is more effective than lengthy appeal

Areas Covered in the Session

• What is Hospital Status (OBS vs. IP) 
• Why is hospital status such a problematic and contentious issue 
• How lax provider documentation facilitates status denials 
• What is an MS-DRG 
• Why and how are certain MS-DRGs targeted 
• What is an MS-DRG downgrade 
• How MS-DRGs are most commonly downgraded 
• What does Medical Necessity mean 
• How Medical Necessity denials can be prevented
• Live Q&A Session

Explore More Trending Courses:

• AI in Action: Real-World Applications for Credentialing and Primary Source Verifications
• Credentialing 101: A Detailed Guide to Provider Credentialing

Suggested Attendees

• Hospital CFOs
• Revenue Cycle Department Members
• Appeals Coordinators
• Clinical Documentation Integrity Specialists
• Hospital Case Managers
• Healthcare Administrators
• Physicians and Non-Physicians Providers
• Medical Coders
• Billing Specialists
• Gastroenterologists
• Clinic Managers
• Nurses
• Experienced Coders
• Experienced Billers
• Clinicians
• Medical Billers
• Healthcare Compliance Officers
• Clinical Documentation Specialists
• Practice Managers
• Health Information Managers
• Medical Office Managers
• Medical Auditors
• Revenue Cycle Analysts
• Medical Reimbursement Specialists
• Coding Educators

About the Presenter

Trey La Charité, MD, FACP, SFHM, CCS, CCDS, is the medical director for CDI, Coding, and Utilization Integrity at the University of Tennessee Medical Center in Knoxville. He is a practicing hospitalist for over 20 years, is a clinical associate professor in the Department of Medicine and is the curriculum director for their residency program’s hospitalist rotation. He has additional responsibilities spanning case management, UR, compliance, quality, performance improvement, and medical records. A past and current ACDIS Advisory Board member, he is a regular presenter at the annual ACDIS meeting and the pre-conference Physician Advisors Forum. He has written several books in the field of CDI that address physician advisor training, program management, and recovery auditor appeals.

Additional Information

After Registration: You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to talk and hear clearly

Live Course Cancellation Policy: If for any reason Skillacquire need to cancel this program, Skillacquire will notify participants by email of the cancellation no less than 24 hours prior to the expected start time.

Can’t Listen Live? No problem. You can get access to an On-Demand webinar. Use it as a training tool at your convenience.

For more information, you can reach out to the below contact:

Toll-Free No: 1-302-444-0162

Email: care@skillacquire.com 

This is a Live Virtual session.

A new way of immersive learning that allows you to engage live with our instructor and peers providing you with the flexibility to juggle the new work-life balance.

Purchase Order Form - Click Here to download PO form. 

Snippet From Our Previous Session

Testimonials