Compliant Managed Medicare Medical Review Claim Submissions

Why Should You Attend:

Managed Medicare claims are becoming more and more scrutinized by Contractors. Small errors or oversights in preparation of claim documents will result in denial of payment and recoupment of monies paid for skilled services.

This course will provide an overview of the critical steps to take when responding to managed Medicare claim review requests. Medical review of claims is an extremely detailed oriented task that must follow the Managed Care Contractor steps to a T. The facility claim manager must employ the interdisciplinary team to manage these claim requests. Managers and support staff will learn how to initiate the process, maintain organizational programs and succeed in insulating claim payments. The process of preparing for claim investigations can be intimidating and overwhelming. Precise protocols will support the team in establishing best practices for successful processing of managed care Medicare claims.

Areas Covered in the Webinar:

• Medical Necessity
• CMS Coverage Manuals
• Medicare Advantages Contracting
• Managed Care Claim Preparation Steps
• Interdisciplinary Expectations
• Claim Submission
• Tracking Strategies
• Denied Claim Approaches

Who Will Benefit:

• Administrators
• Nurse Managers
• Rehabilitation Managers
• Business Office Manager
• MDS Coordinators
• Nursing Staff
• Social Workers
• Therapists

Elisa Bovee
MS OTR/L, Regulatory Expert, Harmony Healthcare International

Elisa Bovee has been working in the healthcare environment advocating for patients through education and clinical guidance. With a degree in Occupational Therapy she has managed a national operations team performing audits and analysis across the US for skilled nursing home providers.

Her expertise includes compliance programs, reimbursement and regulatory, development of education programs, skilled documentation for nursing and therapy and managing claims through the development request and denial phases.

Elisa has presented programs targeting all interdisciplinary groups throughout the country for audiences seeking guidance and clarity on a multitude of regulatory and clinical topics. Additionally, she has written and contributed to articles for national trade publications.

Topic Background:

Medicare contractors must employ the Centers for Medicare & Medicaid Services (CMS) regulatory guidelines. In addition, these contractors have the latitude to establish contractual guidelines for providers. The skilled nursing facility operations team must abide by the Federal and Contractor regulations to maintain a successful and fruitful program. Misfiring during the claim submission process can immobilize and disable a healthcare provider.

Managed Medicare claim medical reviews are rampant throughout the US. This places skilled nursing facilities at high risk for denied claims and revenue take-backs. What does your team know about the Medicare Managed Care Manual? A clear understanding of Medicare advantage contract provisions and requirements will play a critical role in ensuring accurate and appropriate reimbursement. Providers must dive into the CMS' interpretation of the provisions of the Medicare advantage statute and regulations (Chapter 42 of the Code of Federal Regulations, Part 422) which pertain to application procedures and contract requirements.

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