HCPro Medicare Boot Camp® - Utilization Review Version: Aug. 23-24

Time: 8:00 AM


IHA Naperville
1151 East Warrenville Road
August 23-24
8:00am - 4:30pm


IHA members: $1,345 per person
Discounted rate for two or more registrants from one IHA member organization: $1,245 per person

Non-IHA members: $1,695 per person
Discounted rate for two or more registrants NOT from an IHA member organization: $1,595 per person

Tuition includes all program materials, including an extensive program notebook, as well as continental breakfast, lunch and refreshments each day. Travel expenses are the responsibility of the registrant.

Cancellations after June 15 will be charged 50 percent of the registration fee. Registrants who do not cancel and do not attend are liable for the entire fee.

Continuing Education
Continuing education credit is available for coders, health information management professionals, nurses, physicians, case managers, compliance professionals, and certified public accountants (CPAs). Please see the registration website for details.

Register Online

Part of the nationally recognized HCPro Medicare Boot Camp® series, this rigorous two-day program will focus on Medicare’s rules and regulations related to utilization review (UR).

Learn how to maintain regulatory compliance by understanding complex federal rules and appropriately managing patient status. Through a combination of lectures, class discussions and hands-on exercises, this course will examine patient status and the role of the UR committee within the larger context of Medicare rules for coverage, billing, coding, and payment.

New for this course, expert faculty will provide implementation insights for 2018 changes to the inpatient-only list. Participants will also discuss how local and national coverage determinations (NCDs and LCDs) affect coverage of cases that meet the Two-Midnight Rule.


Module 1: Medicare Overview and Contractors Module

  • Medicare Part A, B, C, and D overview
  • Medicare contractors, including the Medicare administrative contractor (MAC), recovery audit contractor (RAC) and quality improvement organization (QIO)

Module 2:  Medicare Research and Resources

  • Finding Medicare source laws, including statutes, regulations and final rules
  • Locating Medicare sub-regulatory guidance, including manuals and transmittals
  • Medicare Coverage Center, including local coverage determinations (LCDs), national coverage determinations (NCDs), coverage with evidence development, (CED) and lab coverage manual
  • Limitations of liability and notice requirements for non-covered services
  • Medicare information and resources for staying current
Module 3: Outpatient Observation
  • Coverage of observation services
  • Medicare Outpatient Observation Notice (MOON)
  • Advanced Beneficiary Notice (ABN) for non-covered observation
  • Observation coding and billing
  • Payment for observation under the Observation Comprehensive Ambulatory Payment Classification (C-APC)
Module 4: Coverage of Inpatient Admissions
  • Inpatient order and certification requirements
  • Inpatient criteria and the Two-Midnight Rule
  • Inpatient-only procedures
  • Admission on a case-by-case basis
  • Documentation and use of screening tools
  • QIO short stay audits
Module 5: Inpatient Utilization Review and Notices
  • Utilization review requirements and self-denials
  • Concurrent review and billing with condition code 44
  • Inpatient Part B payment and billing with condition code W2
  • Important Message from Medicare (IM)
  • Detailed Notice of Discharge (DN)
  • Hospital Issued Notice of Non-Coverage (HINN) for non-covered inpatient services
Module 6: Medicare Payment Fundamentals and Patient Responsibility
  • Outpatient Prospective Payment System (OPPS) basics
  • Part B patient coinsurance
  • Inpatient Prospective Payment System (IPPS) basics
  • Three-day payment window and pre-admission services
  • Medicare-severity diagnosis related groups (MS-DRGs)
  • Payment for transfers and post-acute care transfers
  • Inpatient deductible, coinsurance and lifetime reserve days (LRDs)


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

  • Define observation coverage, billing, coding and payment rules.
  • Explain the Two-Midnight Rule and Two-Midnight presumptions.
  • Summarize changes to the 2018 inpatient-only list.
  • Distinguish between post-discharge versus concurrent patient status reviews.
  • Identify when it is appropriate to bill Part B for a self-denial inpatient case.
  • Demonstrate how NCDs, LCDs and Coverage with Evidence Development (CED) impact coverage of cases that meet the Two-Midnight Benchmark.
  • Explain observation coverage rules and illustrate how they interact with the Two-Midnight Rule
  • Describe how ABNs and HINNs should be used for stays that don’t meet medical necessity requirements

Who Should Attend

  • Utilization review coordinators, managers, directors, committee members, and physician advisors
  • Case managers, care coordinators and nurse managers
  • Compliance officers, auditors and staff
  • Revenue cycle staff
  • CNOs
  • CFOs


Kimberly Anderwood Hoy Baker, JD, CPC
Director, Medicare and Compliance, HCPro

A former hospital compliance officer and in-house legal counsel, Kimberly has over 25 years of healthcare experience, including 10 years of teaching, speaking and writing about Medicare coverage, payment and coding regulations and requirements. She is a lead regulatory specialist and lead instructor for HCPro’s Medicare Boot Camp® - Hospital Version and Medicare Boot Camp® - Utilization Review Version. Kimberly also instructs HCPro’s Medicare Boot Camp® - Critical Access Hospital Version.