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|Presenter:||Eric C. Boughman
|Time:||You can access the webinar anytime
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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 health care system, multiple sources (including government agencies and private companies) operate as payors for health care 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 health care 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 health care 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 which offer an extensive selection of health care plans. Private health care 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 which 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 to prevent future faults.