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Customized Medical Claims Training

CUSTOMIZED MEDICAL CLAIMS TRAINING

“Hands On” Medical Claims Training is available to come onsite at your office.

  • Topics are chosen based on the needs you identify. The program is designed by your selection of practical current topics.
  • Program cost is determined by the combined length of the topics, and includes either copy-ready training materials or pdf files with instructions for assembly.
  • “Hands On” Medical Claims Training is recommended for your claims staff, excess loss clients, and/or claims’ payment users.

Contact us to discuss details of your customized training program requirements.

TOPICS AVAILABLE

For Customized Medical Claims Training you select the topics to be covered, depending on the needs of your staff.  Current topics address the following:

  • Decoding, Billing & More
  • Terms & basic guidelines
  • Coding basics
  • Factors impacting amount billed
  • Chargemaster pricing
  • Chargemaster caution
  • Chargemaster suggestions
  • Technology
  • Operative add-ons
  • Instructions for claims payor
  • Plan language may address
  • Medical necessity issues
  • Preauthorization
  • Fun with modifiers
  • Red flags for review
  • Rebundling tools
  • Before you negotiate
  • Global surgical package
  • Zip code issues
  • Evaluating the coding/bundle
  • Evaluation and Management codes
  • Psychological codes
  • Musculoskeletal system
  • General rebundling tips
  • Evaluating the operative report
  • Resourceful websites
  • Actual cases (genericized)

Eligibility

  • Terms
  • Group eligibility
  • General eligibility requirements for employee
  • General eligibility requirements for dependents
  • Documenting dependent status
  • Documenting Actively at Work status
  • Evidence of Insurability
  • Rescission/Misrepresentation
  • Estoppel
  • General termination guidelines
  • Eligibility fraud
  • Uncovering eligibility issues
  • Proactive suggestions
  • Extra-contractual
  • Stop loss issues
  • Websites
  • Claim examples & sample audit letters & forms

Epogen and Dialysis

  • Definitions
  • Background
  • Reasonable & Customary
  • Audit issues
  • Records
  • Tools for evaluating
  • Epogen protocol
  • Findings
  • One fraud scenario
  • Handling
  • Sample worksheet

Fraud & Abuse

  • Definitions
  • Statistics
  • Background
  • Changes
  • Impacts of Health Care Reform
  • Emergency Services
  • Mental Health/Substance Abuse
  • Rehabilitative & Habilitative Services
  • Preventive & Wellness Services & Chronic Disease Management
  • Medical Necessity Issues
  • New Fraud Schemes
  • Fraud Prevention
  • Past Behavior
  • Approach With Caution
  • Now Potential Fraud & Abuse Have Been Identified
  • Detection Basics
  • Detection Tips
  • Profiling
  • Background Check
  • The Art of Investigating
  • Request Additional Information
  • Do Not Make These Mistakes
  • Indicators of Guilt
  • Identification of Deceit
  • Dealing with Deceit
  • Carefully Review
  • Questions to Ask Billing Forms
  • Next Steps
  • Helpful Websites
  • Exercises, articles and actual cases

Inhospitable Hospital & PP Oh No Issues

  • Definitions
  • Obstacles to managing claims/benefits
  • Medical management strategies
  • Plan design
  • PPO overview
  • PPO contract issues
  • PPO issues
  • Eligibility of facility
  • Red flags
  • Outpatient facility reduction
  • Operative monitoring
  • “Never Events”
  • Hospital auditing 101
  • Quantifying charges
  • Review in terms of plan
  • Questionable billing practices
  • Unbundled hospital services
  • General principles of negotiation
  • Stop loss issues
  • Other helpful web-sites
  • Articles and examples

Infusion Therapy, Implants, Implantable Devices & More

  • Background
  • Types
  • Issues
  • Solutions
  • Claim examples

Partnerships: Administrators, Stop Loss Carriers and Vendors Working Together to Mitigate Losses

  • Background
  • Communication
  • Exercise

Physical therapy

  • Terms
  • Plan considerations
  • Documentation
  • Who’s providing care
  • Fraudulent and/or abusive billing
  • Hands-on or hands-off?
  • Group therapy
  • Timing
  • General guidelines
  • Non-covered
  • Review tips
  • Test, articles and exercise

Plan Language & More

  • Plan design
  • Ask your claims payment system
  • Failure to comply
  • Common problems
  • Resources
  • Difficult issues require tight language
  • Recommendations
  • Sample wording
  • Exercises

Preparing for and Surviving an Audit

  • Who is subject to an audit
  • Why am I being audited?
  • Preparing for an audit
  • “Oh No, the Auditors are Here!”
  • Your rights and responsibilities
  • When an audit goes “bad”
  • Exercise
  • Role play

Substance Abuse & Urine Toxicology

  • Background
  • Billing Forms & Types of Codes
  • Defining Terms
  • Coding
  • CLIA Certification
  • Types of Drug Testing
  • Toxicology Screenings Background
  • Toxicology Screenings: Financial Incentive
  • Compliance/Medical Necessity Issues for Urine Toxicology
  • Sober Homes
  • Policy/Plan
  • Fraud & Abuse Schemes
  • Bypass Payers
  • Datamine & Identify
  • Request, But Proceed with Caution
  • Forensic Investigatory Process
  • Inconsistencies Found
  • Resolution
  • Case Examples
  • Live Investigation (if internet is available)
  • Documentary Movie: Chasing the Dragon (if time permitting)

 

Many other topics are also available. Please contact us for more details on developing a custom training program to meet your needs.