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Eligilibility, Prior Authorization, and Medical Necessity
Recorded Webinar
There are several parts of seeing a patient and receiving payment for professional services. Eligibility ensures that the patient’s insurance coverage is active on the date of service that the services will be rendered and that their plan covers the services planned. There are different methods of receiving eligibility information and we are going to discuss these. Once eligibility is verified, certain procedures require the provider to contact the insurance company to receive prior authorization. Unfortunately, every insurance company has different requirements, making it difficult to manage. It is important that offices keep track of the current policies for the insurance companies they work with the most, and ensure these authorizations are performed prior to the service being performed. Medical necessity is normally reported by the ICD-10-CM codes. These codes justify why a procedure or service is performed based on the patient’s condition. The insurance companies may have policies that define the services they consider medically necessary based on the diagnosis. If the information on the claim does not meet their guidelines, the claim will be denied.
Insurance companies are requiring that authorization for services be obtained for more services and procedures. It is also common that employers will change insurance plans to save money on monthly premiums. This session will walk through how offices can obtain eligibility before the patients are seen to confirm that the insurance information that is available is accurate and the patient is covered for services to be rendered. Then when the patient is seen, any services or procedures that are ordered may need to be prior authorized for that reimbursement will be received. The final piece is that the medical necessity requirements for the procedure or service is being met according to insurance company policies and guidelines. Attendees will benefit from this webinar in that we will discuss all of these aspects of a medical claim that may have to occur before the insurance company even processes it and will reduce the number of claims an office can receive because these steps were not taken.
Venue: Recorded Webinar
Critical Access Hospitals (CAHs) must comply with the Centers for Medicare & Medicaid Services’ Conditions of Participation located in Appendix W in the manual. This eight-part webinar series will cover the CAH CoP manual. There were changes and new regulations for CAHs in 2020, including a change to all the tag numbers, some which do not include Interpretive Guidelines or Survey Procedures. Changes include infection prevention and control and antibiotic stewardship, QAPI and Swing Bed changes. This seminar will help CAHs comply with specific CoP problem areas, such as nursing care plans, necessary policies and procedures, medication administration and drug storage, and informed consent to name a few. Part Three of Eight: Physical Plant & Environment, Emergency Preparedness Objectives Describe expectations for a safe environment for patient care Recall the requirements for equipment maintenance and an alternative management program Explain the importance of maintaining ventilation, temperature, and lighting within a CAH Describe the mandatory training and exercises for an emergency preparedness plan Physical Plant and Environment Construction and maintenance Equipment, preventive maintenance and AEM Physical environment Disposal of trash Storage of drugs Life Safety from Fire LSC waivers Fire inspections Emergency Preparedness Emergency Plan Policies and procedures Communication Plan Training and testing Power systems Appendix and Resources
Calling all medical coding professionals, CDI and auditors, it’s that time again! Join us as we take a deep dive on all updates related to the Official Guidelines for Coding and Reporting for fiscal year 2025. Together, we will be evaluating all affected diagnosis codes which includes additions, deletions and revisions. Knowledge is power so let’s be proactive and review our updated guidelines to ensure quality reporting, accuracy, compliance and proper reimbursement. Webinar Objectives Review the changes to the Official Guidelines for Coding and Reporting FY 2025 Know diagnosis codes that were deleted, added and revised in each affected chapter Understand documentation best practices in impacted diagnosis codes Questions and Answers Who Should Attend HIM Coding Directors, Managers, Supervisors Hospital Coding Staff Clinical Documentation Improvement Management and Staff Reimbursement Specialists Coding Compliance Management and Staff Auditors and Educators
ICD-10-CM updates for 2025 will become effective on October 1, 2024. These updates will include several guideline changes as well as multiple updates & additions to the specific chapters. This webinar will discuss the new guidelines as well as specific code categories in which you need to be alert to changes that may impact your code selection. All chapters will be included to ensure your specialty is covered. It is important that you be proactive and prepared when submitting your claims with discharge dates of October 1. Missed update information may cause a processing & reimbursement delay. Webinar’s Goals Be aware of guideline changes Learn about chapter specific additions & updates Ensure you are prepared with new code information Align with your software vendors to implement any necessary changes Target Audience Revenue Cycle Managers & staff Billers Coders Clinical Documentation Staff Finance Managers Denial Management Staff Physicians Mid Level Providers Claims Follow Up Staff
In addition to finalizing payment rates, the 2024 Final Rule includes promoting health equity, expanding access to behavioral health, improving transparency and promoting safe, effective and patient-centered care. The following areas will be covered in this webinar: Updates to OPPS & ASC Payment Rates Intensive Outpatient Program Scope of Benefits for Intensive Outpatient Program Physician Certification & Plan of Treatment Requirements Intensive Outpatient Program Payment Rates & Policies Opioid Treatment Program Settings Partial Hospitalization Program Changes to Community Mental Health Centers Conditions of Participation Remote Mental Health Services Payment for Dental Services Rural Emergency Hospitals Transitional Pass-Through Payment for Devices OPPS Payment for Dtrugs Acquired Through 340B Program Webinar’s Goals Provide clarity of Final Rule content and effects on your provision of services Advances Centers for Medicare & Medicaid Services’ commitment to strengthening Medicare Changes that will help address health inequities Use of lessons learned from COVID-19 PHE to inform approach to quality measures Target Audience Physicians Practice managers Medical assistants Nurses Compliance staff Billers Coders Revenue Cycle Risk Management Charge entry staff Finance Staff Therapists