Denials Avoidance &
Appeals Institute (C-DAM)
Overall Learning Objectives
At the completion of this program, participants should be able to:
• Identify the challenges inherent in interpreting the payer payment systems, denial management and how to have your facilities prepared for success with appeals.
• Understand the changing state of today’s healthcare system, as related to the important trends toward required compliance activities to prevent future claims denials.
• Identify the diverse educational needs for healthcare personnel regarding the significant changes in the healthcare reimbursement field and how these impact the denials that an organization will confront.
• Identify important methods of (and how to manage) administrative & provider organizational acceptance and “buy-in” to improve the denial management and appeals processes.
• Describe the goals, key benefits, and strategies of having an on-site based denial management and appeals program.
• Identify effective techniques to communicate with both clinicians (physicians, mid levels, nurses, care managers) and non-clinical (coding & billing) staff in order to appeal current denials and prevent future denials.
• Apply techniques to develop and implement a structured Denial Management and Appeals Improvement Program within acute care hospitals.
• Identify compliance methods on auditing, monitoring, and evaluating the effectiveness of your denial management program.
• Accurate, precise and explicit medical records documentation
• Effective case management processes including level of care assignment
• Correct and compliant coding that reflects the true severity of illness and complexity of care
For more information about our programs contact:
DENIALS AVOIDANCE & APPEALS MANAGEMENT INSTITUTE (C-DAM) AGENDA
OVERVIEW OF THE REVENUE CYCLE (35 Minutes)
1. Explain the Revenue Cycle
2. Define The components of the Revenue Cycle
3. Identify How the Revenue Cycle “breaks down”
HOW HEALTH CARE GETS PAID (50 Minutes)
4. Delineate policies governing third party payment
5. Differentiate Reimbursement policies
6. Analyze the challenges with payment structures
8. Identify the causes of denials
9. Review the regulatory processes in denials
10. Evaluate “Where do we go from here”
DENIALS – Continued
THE RIGHT SETTING AT THE RIGHT TIME – INPATIENT VERSES OUTPATIENT (1 Hour 20 Minutes)
11. Delineate in detail the differences between Inpatient and Outpatient status.
12. Review and Examine Medical Necessity.
13. Discuss the responsibilities and obligations of the treating physician.
14. Review the vital role of Clinical Documentation.
15. Examine the review process and the rationale of contracted reviewers.
DENIALS & APPEALS MANAGEMENT (1 Hour 5 Minutes)
16. Summarize strategies to reduce clinical denials
17. Recognize Case Management and Utilization Management roles in the revenue cycle
18. Identify how clinical documentation programs effect the revenue cycle
19. Discuss strategy to build an effective Denial & Management program
THE APPEAL PROCESS (1 Hour 15 Minutes)
20. Recognize what type of appeal is necessary.
21. Utilize a strategy for appeal management.
22. Investigate & analyze the medical record.
A FIVE STEP STRATEGY TO WRITING EFFECTIVE CLINICAL APPEAL LETTERS (1 Hour 10 Minutes)
23. Validate defense with standard practices of evidence based medical criteria.
24. Quote clinical documentation that is explicit and supports the issue being denied.
25. Summarize coherently the rationale in defense of the denial.
26. Demonstrate how to write compliant health care appeals.
DENIALS AVOIDANCE & APPEALS MANAGEMENT INSTITUTE ACCREDITATIONS
THE COMMISSION FOR CASE MANAGER CERTIFICATION (CCMC)
This program has been pre-approved by the Commission for Case Manager Certification to provide continuing education credit to Certified Case Managers (CCMs). The course is approved for 12.5 CE contact hour(s). Activity Code: S00039494 Approval Number: 190004018.
10/25/19 – 10/25/20
To claim these CEs, log into your CE Center account at www.ccmcertification.org
THE OHIO NURSES ASSOCIATION (ONA)
This program has been approved by The Ohio Nurses Association Continuing Education Department for 12.5 CE contact hour(s). (ONA #21862)
The application was reviewed based on ANCC criteria and Ohio Board of Nursing rules. The criteria were met.
Approval valid through 11/14/2020
The Ohio Nurses Association is an accredited approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)
IS IT TIME TO RECERTIFY?
C-DAM Re-Certification Fee $150