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Laura Legg RHIT, CCS, CDIP, AHIMA approved ICD-10 CM/PCS

Trainer HRG Executive

Director of Revenue Integrity and Compliance

Presented by:

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RAC: What Can You Expect in 2017?

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RAC New Statement of Work – Get Ready by:

• Centralizing your audit team• Reducing denial rate• Sending out complete medical records• Improving response rate and efficiency

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MOON Update E

DICARE

UTPATIENT

BSERVATION

OTICE

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Medicare OutPatient Observation Notice (MOON) Update

• Who should explain MOON to the patient?• When should notice be given?• What documentation must be included in the patient

record?• How can we help the patient understand possible

reimbursement consequences?

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How Do CDI & Coding Effect The Revenue Cycle• Case Mix Index changes in 2016• Two new coding metrics specific to ICD-10• Breaking down silos so real work can begin• Benchmarking high-risk DRGs

Admission Certification

Correct Billing Edits

Refund Credit

Balances

Receive and process

remittance

Research Denials

Revenue Cycle

Physician Referral To HCO

Medical Necessity

Verification

Pre-Registration

Pre-Authorization

Eligibility Assessment Collect Co-Pays

& DeductiblesVerify Surgery-Inpatient Only?

Update Chargemaste

rManaged Care

ContractManagement

Discharge Planning

Continued Stay

Certification

Charges Submitted

ED Charges/Levels

Late Charges

Surgical Authorization

Bill Secondary Payers

Electronically Process Claims

Post & Deposit Payments

Data Collection & Analysis

AR Monitoring

Cash Flow Analysis

AuditsComplianc

e

Discharge Record

Retrieval

Issue ABN

Denials Management

Team

Case Manageme

ntOrders

Financial Assessment

CodingPhysician

Documentation

Improvement

Coding Audits

Appeal

Spokes of the Cycle

Created by Rose T. Dunn hrgpros.com

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DRG Downgrading

A tug-of-war worth fighting!

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DRG Downgrading Due To Missing Clinical Validation

• Six top diagnoses to audit pre-bill• Documentation required when clinical validation is

missing• How to effectively appeal denials for clinical validation• Just how much $$$ are we talking about

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Laura Legg,RHIT, CCS, CDIP, AHIMA

Approved ICD-10 CM/PCS Trainer

HRG Executive Director of Revenue Integrity &

Compliance

Visit us online for the in-depthoverview of this presentation and to find out where to see Laura in-person at upcoming speaking engagements

hrgpros.com/2017-industry-changes

800.695.8171 YourPartner@hrgpros.com@hrgpros #WeAreHRG