Navigating Medical Necessity Denials Management for All Payers

8 Nov 2016 10:00 AM | Ronald Gallagher (Administrator)
Speaker: John Zelem, MD

The resumption of audits from Quality Information Organizations (QIOs) and the impending referrals to Recovery Auditors has the potential to increase government denials and add to an already backlogged appeals caseload. The inevitable reality of claims denials plagues every hospital.
Managing denial and appeal processes can be a long and frustrating undertaking. As commercial and managed Medicare/Medicaid denials continue to grow and QIO inquiries and ALJ backlog add additional uncertainty to government denials, hospitals face serious threats to their financial health from revenue lingering in denial limbo.

Learning Objectives:
  • Identify the current environment for medical necessity denials from all payers
  • Discuss the standard appeal processes for medical necessity denials
  • List what should be included in a denials management and prevention strategy

Take Away:
This presentation provides best practices for managing medical necessity denials from all payers – commercial, managed Medicare/Medicaid, and government – and examples of how some facilities are addressing the growing threat to their revenue from medical necessity denials.

Speaker Biography:
Dr. Zelem is Vice President, Compliance and Physician Education, at Optum Executive Health Resources. Dr. Zelem is responsible for quality assessment and improvement at Optum Executive Health Resources’ client hospitals and works closely with Optum Executive Health Resources’ sales team. In addition, Dr. Zelem travels to Optum Executive Health Resources’ client hospitals regularly to provide medical executives and staff members with ongoing education on a variety of topics including Medicare and Medicaid compliance and regulations, medical necessity, Recovery Audit Contractors, utilization review, denials management and length of stay. Prior to joining Optum Executive Health Resources, Dr. Zelem practiced general surgery for 24 years at Griffin Hospital, a 160-bed acute care community hospital located in Derby, Conn., and then practiced general surgery for two years at Baptist Memorial Hospital-Booneville, a 67-bed acute care hospital located in Booneville, Miss. Dr. Zelem received his medical degree from Boston University School of Medicine and bachelor’s degree in biology from Boston College.
Field of Study: Specialized Knowledge
Delivery Method: Group Internet Based
Program Level: Intermediate
Prerequisite(s): None
Advanced Preparation: None
Cost: Free
CPE Hours: 1.0 Hours CPE
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