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Adapting Your Medical Necessity Compliance Program in an Evolving Regulatory Environment

13 Oct 2016 11:00 AM | Ronald Gallagher (Administrator)
Speaker: Dr. Joydip Roy

Slide Deck:

How will you ensure your hospital withstands auditor scrutiny in 2016 given the expected changes from Centers for Medicare & Medicaid Services (CMS) to address the persistently large improper payment rates in short-stay inpatient claims? Hospitals should evaluate their current compliance programs regularly. With medical necessity changes CMS is proposing, the best way to defend against inappropriate denials is to ensure a compliant process for review and certification of admission status on every patient that enters the hospital. With a renewed emphasis on physician judgment and medical necessity, not hospital level of care, providers must demonstrate a legitimate, defensible and consistent Utilization Review process to determine appropriate admission status. Hospitals across the country may struggle with this proposed shift, especially considering the time-based recommendations implemented in 2014. It is challenging to anticipate projected enforcement under the QIOs with their extensive referral possibilities. This session will provide guidance on the implications of proposed changes from CMS and the potential impacts to your medical necessity admission review program.

Learning Objectives:
  • Discuss trends and lessons learned from Probe and Educate efforts.
  • Identify potential QIO enforcement ramifications and discuss the extensive referral opportunities that could impact hospitals.
  • Discuss policies and practices implemented under FY 2014 IPPS, related to the 2 midnight rule, and determine if current programs would align with a renewed emphasis on provider judgment and medical necessity for inpatient hospital admissions.

Take Away:
This session will assist hospitals in evaluating their current medical necessity admission review program and help determine if there could be a possible overuse of observation status at their facilities.

Speaker Biography:
Dr. Roy currently serves as Vice President, Compliance and Physician Education, at Executive Health Resources (EHR), a national organization that provides technology-enabled, expert Physician Advisor teams concentrating on managing Medicare and Medicaid regulatory compliance, minimizing inappropriate medical necessity denials and achieving appropriate lengths of stay in acute care hospitals and health systems. At present, EHR works with more than 2,300 hospital and healthcare organizations across the country, has an exclusive endorsement of the American Hospital Association and has received the elite Peer Reviewed designation from the Healthcare Financial Management Association.Board Certified in internal medicine, Dr. Roy completed training in internal medicine and pediatrics at Baylor College of Medicine. Dr. Roy is a member of the American College of Physicians. He earned his medical degree from the University of Tennessee College of Medicine in Memphis, Tenn.

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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