Revenue Integrity and Chargemaster Boot Camp


Nov 16, 2020 – 8:00 AM - 5:00 PM

(daily for 4 times)

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Revenue Integrity and Chargemaster Boot Camp
About this Event


Course Overview

The Revenue Integrity and Chargemaster Boot Camp provides education on chargemaster and revenue integrity concepts in a classroom format. The program will relate the chargemaster function to revenue cycle and revenue integrity functions, including cost reporting and key operational issues, such as coverage, clinical documentation, charge capture, and coding.

It will also provide context for chargemaster set-up and maintenance within revenue integrity with an objective to help avoid pre- and post- billing edits and payer denials.

You will leave this program knowing how to:

Provide formal, organized education and training for revenue integrity and chargemaster staff
Provide context for the intersection of the chargemaster with clinical/revenue departments, charge capture, coding, finance, and patient access and billing
Walk attendees through CMS regulatory requirements for pricing and charging patients, as well as key relationships between the chargemaster and provider cost reporting
Give detailed instructions for the majority of revenue codes for optimal chargemaster setup, maintenance, charge capture, and documentation issues
Review chargemaster issues for commercial/managed care versus CMS requirements

Learning Objectives

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

Equip hospital, payer and other healthcare specialists with effective and efficient strategies to obtain and maintain overall 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 fee-for-service Medicare requirements as a framework
Explain standard charge description master (CDM) elements, design and 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 by revenue code with associated cost reporting principles
Exemplify outpatient and inpatient hospital prospective payment systems reimbursement and rate setting methodologies as well as appeal strategies to protect revenue


Module 1: Revenue Integrity Overview and Resources

Revenue integrity functions and key principles including how the chargemaster fits into over revenue integrity functions

Medicare and other revenue integrity and chargemaster resources

Understanding authoritative sources such as statutes, regulations, manuals, transmittals and other Medicare rules and guidelines

Module 2: Eligibility Principles

Review major and different types of medical insurances

Principles of health insurance eligibility and verification of insurance

Coordination of Benefits & Subrogation

Medicare Secondary Payer (MSP) concepts

Module 3: Benefits, Coverage and Medical Necessity

Review how insurance benefits are structured for hospital and other services

The importance of coverage, medical necessity and both implied and specifically excluded benefits

Medicare’s prohibition against unbundling for inpatient and outpatient hospital services

Pre-service coverage analysis and associated waiver/notice requirements

Serious preventable events and relationship to risk management

Investigational/experimental services and implications for coverage

Module 4: Provider Types, Licensure, Enrollment, & 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

Licensure, scope of practice, privileging and relationship to coverage

Conditions of participation, survey & certification and accreditation

Importance of medical staff bylaws & regulations and relationship to conditions of payment

Exercises: Concepts of Revenue Integrity

Module 5: Charge Description Master Structure and Charge Capture Principles

Definition, purpose and key fields of a chargemaster

Concepts for code set up in CDMs and relationship to HIM coding

Principles of bundled services per CPT definition vs reporting packaged services and implications for separate charging of packaged services

Strategies to address payer differences in the chargemaster

The relationship of chargemaster to overall AR System

Concepts for pricing services and why APCs are not a good gauge for pricing hospital services

Chargemaster, general ledger and relationship to cost reporting

Module 6: Claims Submission Fundamentals and Code Edits

Key UB-04 fields applicable to hospital services

HIPAA transaction sets including ICD-10 and HCPCS codes

Common claim edits including NCCI and MUEs

Other transaction sets applicable to the revenue cycle such as eligibility, payment, claim status and denial transaction sets

Module 7: Special Medicare Billing Issues

Billing requirements for outpatient repetitive versus non-repetitive recurring and non-recurring services

The three-day payment window and outpatient services billed on inpatient claims

Billing of non-covered inpatient and outpatient services

Patient status and billing 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 revenue codes associated with routine services and observation

Major factors of coverage for these services

Applicable inpatient and outpatient payment concepts

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 services, emergency, cardiology, diagnostic imaging, pharmacy and supplies

Coding and edit issues for revenue codes associated with ancillary services

Major factors of coverage for these services

Applicable inpatient and outpatient payment concepts

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 service departments, including respiratory therapy, clinics, behavioral health, and preventive services

Coding and edit issues for revenue codes associated with other departments

Major factors of coverage for these services

Applicable inpatient and outpatient payment concepts

General ledger and finance considerations including pricing and charge capture

Exercises: Routine and Ancillary Services by Revenue Code

Module 11: Introduction to Payment Systems

Review inpatient payment systems including DRGs, APR-DRGs, Case Rates and Per Diems

Discuss hospital outpatient hospital payment systems including OPPS & APCs, eAPGs, fee schedules and percent of charges

Review outpatient surgery payment methodologies such as ASC and ambulatory fee schedules

Review other ambulatory service payment systems such as the physician fee schedule (MPFS), DMEPOS, Clinical Lab Fee Schedule

Review emerging payment methodologies such as Bundled/Episode Payments (CJR) and Value-Based Purchasing

Module 12: Outpatient Prospective Payment System (OPPS)

Understanding OPPS payable services and structure of APCs

Learn how to determine whether services are paid separately or packaged

Understand C-APCs and complexity adjustments

Understand impact of inpatient deductible cap on co-payments for beneficiaries

Module 13: Medicare Physician Fee Schedule (MPFS)

The 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

Exercises: Payment Systems

Module 14: Charge Description Master Management and Maintenance Strategies

Issues surrounding the annual chargemaster updates including pricing, HCPCS codes, charge items with no volume

Strategies to work collaboratively with departments

Importance of patient account and charge reconciliation

Tracking CDM changes for compliance

Charge integrity monitoring and reducing unexplained variation in claims

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 external auditors from commercial plans

Module 16: Payer Contracting Strategies

Concept and criteria for carve out options

Importance of tracking administrative cost by payer and developing and trending payer scorecards

Contract negotiations and annual price increase limits/caps applicable to chargemaster

Exercises: Strategies for CDM Management, Denials and Payer Contracting

Course Outline/Agenda subject to change.


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