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CMS & Commercial Payer Audit Risks & Targets: SIUs and MAC Audits

$251.00$549.00

Session Information:
By: Eric C. Boughman
Format: On-Demand Webinar
Duration of the training: 60 Minutes
SKU: SA00016 Categories: ,

Conference Material (Password Required)

The United States has a unique hybrid, multi-payer healthcare system, which is made up of public payors, including federal, state, and local government agencies, and private payors, including commercial health plans (offering employer-based coverage and individual coverage) and individuals (paying out-of-pocket for costs where uninsured, for benefits not covered, or as an assigned portion of responsibility for total costs under a health plan). Multi-payer means a healthcare system that is financed by more than one single entity. In the multi-payer healthcare system, multiple sources (including government agencies and private companies) operate as payors for healthcare services performed by private suppliers.

With a value-based care model gaining more relevance in the United States health care system, payer audits are becoming more usual. Insurance providers assert say that audits are performed to enhance the quality of the service that the patients obtain from the health care providers.

In this seminar, attorney Eric Boughman addresses the fundamentals of healthcare payers and reimbursement, payment and delivery systems, public and private payers, and alternative payment models and options. Eric will also talk about payment audits, related laws and regulations, and the most important points related to the payer audits process.

In discussing the healthcare payers and reimbursement, Eric will discuss the background of payment and delivery systems, such as Fee-for-Service (FFS) and Managed Care systems. Attendees will learn about public and private payers. Within the category of public payers are Medicare and Medicaid, the Military and Veteran Care, the Veterans Health Administration, the Indian Health Service, and the Federal Employees Health Benefits Program. The private payors are usually health insurance companies that offer an extensive selection of health care plans. Private healthcare coverage is generally split into employer-based coverage and individual coverage. Eric will also discuss alternative models and options such as self-pay and direct patient contracting.

From a payer audits perspective, this seminar will review the laws and regulations related to payer audits. We will also discuss various entities such as the Special Investigative Unit (SIU), Contractors, and Medicare Administrative Contractor (MAC), which are bound by laws and contractual obligations; contracts, governing documents and policies for payers, medical record review, medical necessity and treating physician rule.

Although it is essential to identify and understand the elements of the payer audit process, it is also important to know what steps to take when you receive an audit. The audit begins with a notification letter that identifies the entity conducting the audit. We will discuss how providers are targeted through data analysis by the Centers for Medicare & Medicaid Services (CMS) or their contractors, and collaborative efforts between the States and CMS.

Finally, we will cover a case study where the audit process and the response from the staff of the audited entity will be analyzed. We will discuss how they were notified, what they did at the beginning, and how they had to change and improve some internal processes to comply with the requirements and prevent future faults.

Learning Objective:
  • Knowing the background of healthcare payment and reimbursement
  • Identifying the payment and delivery systems
  • Identifying public and private payors
  • Knowing alternative payment models and options
  • Understanding ex post facto laws
  • Knowing SIUs, contractors and MACs
  • Knowing contract/governing documents and policies
  • Understanding the medical record review
  • Knowing the credentials of reviewers
  • Understanding credential files
  • Understanding signature requirements
  • Understanding medical necessity
  • Understanding treating physician rule
  • Understanding the judgment error
  • Understanding the audit process
Areas Covered in the Session:
  • Background of healthcare payment and reimbursement
  • Payment and delivery system
  • Public and private payors
  • Alternative payment models and options
  • Ex post facto laws
  • SIUs, contractors and MACs
  • Medical record review
  • Credentials of reviewers
  • Credential files
  • Signature requirements
  • Medical necessity
  • Treating physician rule
  • Judgment error
  • Audit declaration
  • How did they find you?
  • Case study
  • Resources and tools
Suggested Attendees:
  • Healthcare providers and staff.
  • Hospital and healthcare facility administration.
  • Vendors and contractors who work in the healthcare sector.
  • Legal counsel and other professional advisors to healthcare providers
  • Physician
  • Nurses
  • Physician Assistants
  • Healthcare Billing and Coding Staff
  • Credentialing and Enrollment Specialists
  • Healthcare Administrative Personnel
  • Clinic Managers
  • Credentialing and Enrollment Specialists
  • Healthcare Administrative Personnel
  • Practice Managers
  • Auditors
  • Compliance Officers
  • Medical record supervisors
  • Health Information Management Administrators and Technicians
  • Other Personnel Interested in Billing Privileges with the Medicare Program
Presenter Biography:

Eric Boughman is an AV-Rated Attorney and Certified Circuit Court Mediator whose law practice focuses on serving clients in the business of healthcare, technology, and other select industries. He relies on a diverse background to solve complex legal issues with a focus on compliance, risk management, and avoiding or reducing exposure from legal threats and lawsuits. His clients include businesses, professionals, investors, and entrepreneurs.

Eric spent the first decade of his career as a business litigator representing clients of all sizes, from Fortune 500 companies to local startups, in complex legal disputes. Over time, his experience and expertise grew, and Eric expanded his practice to provide a full range of comprehensive legal services, including regulatory, transactional, and general counsel for companies in the healthcare, technology, and med-tech space.

Eric particularly enjoys helping clients avoid legal troubles and aiding settlement among parties in dispute. The most rewarding components of his practice involve serving as a mediator (a neutral facilitator whose mission is to settle legal disputes) and general counsel services he provides for clients on a flat-fee basis.

Eric is a frequent writer and presenter on issues involving health law, privacy, technology, and asset protection. His writings have appeared in multiple American Bar Association publications, The Florida Bar Journal, Forbes, Daily Business Review, Accounting Today, Kiplinger, Financial Advisor Magazine, Law360, and CEO World, among others.

Eric is admitted to practice law in Florida and Nevada, as well as in the U.S. Tax Court, and in several other courts, nationwide, pro hac vice. He is active with local bar associations, including serving as an appointed member of his local jurisdiction’s grievance committee, and is also active in several charitable endeavors in his local community.

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