HCPro Revenue Integrity and Chargemaster Boot Camp®: July 23-26

Time: 8:00 AM

Location:

IHA Naperville
1151 East Warrenville Road
Naperville, IL

Registration:

IHA members: $1,745 per person
Discounted rate for two or more registrants from one IHA member organization: $1,645 per person

Non-IHA members: $2,195 per person
Discounted rate for two or more registrants NOT from an IHA member organization: $2,095 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 May 18, 2018, 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, case managers, compliance professionals, and certified public accountants (CPAs). Please see the registration website for details.

Register Online

Part of HCPro’s best-in-class Compliance and Regulatory Training Solutions, this rigorous four-day course will equip you with the tools and expertise to achieve operational efficiencies and improved reimbursement within your organization.

This program, offered for the first time by IHA, provides comprehensive instruction on chargemaster and revenue integrity concepts. Participants will learn how the chargemaster function is critical to the revenue cycle, cost reporting and key operational concepts such as coverage, clinical documentation, charge capture, and coding. Expert faculty will provide context for chargemaster maintenance within revenue integrity processes, which can help avoid denials and improve clean claim rates for Medicare and other payers.

Agenda

Module 1: Revenue Integrity Overview and Resources

  • Revenue integrity functions and principles, including how the chargemaster relates to revenue integrity functions
  • Medicare revenue integrity and chargemaster resources
  • Statutes, regulations, manuals, transmittals, and other Medicare rules and guidelines

Module 2: Eligibility Principles

  • Review major and different types of medical insurances
  • Health insurance principles, eligibility and verification
  • Coordination of benefits and subrogation
  • Medicare Secondary Payer (MSP) concepts

Module 3: Benefits, Coverage and Medical Necessity

  • Insurance benefit structures for hospital and other services
  • Coverage, medical necessity and implied and specifically excluded benefits
  • Medicare prohibition against unbundling for inpatient and outpatient services
  • Pre-service coverage analysis and waiver/notice requirements
  • Serious preventable events and risk management
  • Investigational/experimental services and coverage implications

Module 4: Provider Types, Licensure, Enrollment, and Privileges

  • Types of facilities, providers, physicians, practitioners, and suppliers
  • Provider-based department requirements, including implications of Section 603 of the Bipartisan Budget Act of 2015
  • The relationship of licensure, scope of practice and privileging to coverage
  • Conditions of Participation, survey, certification, and accreditation
  • Importance of medical staff bylaws and regulations, and relationship to conditions of payment
  • Exercise: Concepts of Revenue Integrity

Module 5: Charge Description Master Structure and Charge Capture Principles

  • Chargemaster definition, purpose and key fields
  • Charge Description Master (CDM) code concepts and relationship to health information management (HIM) coding
  • Principles of Current Procedural Terminology (CPT)-defined bundled services vs. reporting packaged services and implications for separate charging of packaged services
  • Strategies to address payer differences in the chargemaster
  • The relationship of the chargemaster to overall accounting revenue
  • Pricing services concepts
  • The relationship between chargemaster, general ledger and cost reporting

Module 6: Claims Submission Fundamentals and Code Edits

  • Key UB-04 fields for hospital services
  • HIPAA transaction sets including ICD-10 and HCPCS codes
  • Common claim edits including National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs)
  • Other transaction sets such as eligibility, payment, claim status, and denial

Module 7: Special Medicare Billing Issues

  • Billing requirements for outpatient repetitive, non-repetitive recurring and non-recurring services
  • Three-day payment window and outpatient services billed on inpatient claims
  • Billing non-covered inpatient and outpatient services
  • Patient status and the billing of inpatient non-medically necessary services
  • Exercises: CDM Structure, Claims and Billing Issues

Module 8: Strategies and Key Issues by Revenue Code: Routine Services and Observation

  • Key concepts for accommodation codes and routine services, including outpatients in beds, specialty care units and observation services
  • Coding and edit issues for routine services and observation revenue codes
  • Major coverage factors
  • Applicable inpatient and outpatient payment
  • General ledger and finance considerations including pricing and charge capture

Module 9: Strategies and Key Issues by Revenue Code: Ancillary Services

  • Key concepts for major ancillary service departments including peri-operative, emergency, cardiology, diagnostic imaging, pharmacy, and supplies
  • Coding and edit issues for ancillary services revenue codes
  • Major coverage factors
  • Applicable inpatient and outpatient payment
  • General ledger and finance considerations including pricing and charge capture

Module 10: Strategies and Key Issues by Revenue Code: Other Departments

  • Key concepts for other common ancillary services including respiratory therapy, clinics, behavioral health, and preventive services
  • Coding and edit issues for revenue codes associated with these departments
  • Major coverage factors
  • Applicable inpatient and outpatient payment
  • General ledger and finance considerations including pricing and charge capture
  • Exercises: Routine and Ancillary Services by Revenue Code

Module 11: Introduction to Payment Systems

  • Inpatient payment systems including DRGs, APR-DRGs, case rates and per diems
  • Hospital outpatient payment systems including OPPS and APCs, APGs, fee schedules, and percent of charges
  • Outpatient surgery payment methodologies such as ASC and ambulatory fee schedules
  • Ambulatory service payment systems such as the Medicare Physician Fee Schedule (MPFS), durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), and Clinical Lab Fee Schedule
  • Emerging payment methodologies such as Comprehensive Care for Joint Replacement (CJR) bundled/episode payments and Value-Based Purchasing

Module 12:  Outpatient Prospective Payment System (OPPS)

  • OPPS payable services and APC structure
  • Services paid separately or packaged
  • Comprehensive-APCs and complexity adjustments
  • Impact of inpatient deductible cap on beneficiary co-payments

Module 13:  Medicare Physician Fee Schedule (MPFS)

  • Resource-based relative value system
  • Relative value unit (RVU) structure
  • Site of service adjustments for facility and non-facility services
  • Global versus technical and professional components
  • Payment policy indicators
  • Exercise: Payment Systems

Module 14: Charge Description Master Management and Maintenance Strategies

  • Annual chargemaster updates including pricing, HCPCS codes and charge items with no volume
  • Strategies to work collaboratively with departments
  • Patient account and charge reconciliation
  • Tracking CDM changes for compliance
  • Charge integrity monitoring and reducing unexplained claims variation

Module 15: Denial Management

  • Principles of denial management
  • Adjustment claims and automated provider reopening
  • Initial and revised determinations and appeal rights
  • Levels of appeal and timelines for filing
  • Types of auditors including commercial plans’ external auditors

Module 16: Payer Contracting Strategies

  • Concept and criteria for carve-out options
  • Tracking administrative cost by payer and trending payer scorecards
  • Contract negotiations and annual price increase limits/caps applicable to chargemaster
  • Exercises: Strategies for CDM Management, Denials and Payer Contracting

Objectives

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

  • Provide hospital staff with effective and efficient strategies to achieve and maintain revenue integrity for both governmental and non-governmental payers.
  • Gain a working understanding of revenue integrity principles associated with eligibility, coverage, coding, billing, and payment using Medicare requirements as a framework.
  • Explain standard charge description master (CDM) data elements, relationship to the general ledger and revenue cycle processes of coding and billing.
  • Review claim requirements and specific issues of CDM set-up and maintenance.
  • Determine outpatient and inpatient hospital prospective payment systems reimbursement and rate setting methodologies.
  • Apply appeal strategies to protect revenue integrity.

Who this is for

  • Reimbursement management and staff
  • Chargemaster staff
  • Patient financial services management and staff
  • Managed care contracting management and staff
  • Revenue integrity management and staff
  • Health information management staff
  • Compliance office management and staff
This 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.

Speakers

John D. Settlemyer, MBA, MHA, CPC
Adjunct Instructor, HCPro Revenue Integrity and Chargemaster Boot Camp®
Assistant Vice President, Revenue Cycle, Atrium Health

With 25 years of experience in healthcare finance and reimbursement, John is a highly regarded expert in Medicare Outpatient Prospective Payment System (OPPS) coding and billing. He is a charter member and inaugural chairperson – serving two terms – of The Provider Roundtable, a national group of volunteer providers whose focus is providing comments to CMS on the operational and financial impact of OPPS proposed rules. He has made numerous presentations in front of the Medicare Advisory Panel on hospital outpatient payment.

In his role at Atrium Heath, John’s focus is on Chargemaster (CDM) compliance, charge capture and revenue integrity. He has direct or consulting oversight of the CDM for all Atrium Health hospitals and their associated outpatient care locations, such as provider-based clinics, healthcare pavilions and freestanding emergency departments.

John also serves as a North Carolina HFMA chapter member and most recently began serving as an Advisory Board member for the National Association of Healthcare Revenue Integrity (NAHRI).