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Disallowing Charges, Medical Necessity, Unbelievebility Denials and Effective Appeals
Speaker: Rebecca S. Busch RN, MBA, CCM, CBM, CHS – III, CFE, FHFMA
In the early 1980’s the typical audit of a claim involved simply the verification of a service provided by a provider. Today the evolving concepts of audit include the assumption that the service was provided in addition to the quality of the service, the rational, and the necessity of the service. We have the added dimensions of justification including who what where why and how. The art is now in the review and analysis of the audit and the ability to verify any third party finding. This session will highlight critical data elements that any system should include and how to develop data driven responses to third party reviews.
1. Introduce data trends from a provider and payer perspective.
2. Review current metric and evolving metrics to be applied.
3. Review critical data elements that any system should maintain and or develop.
4. Introduce Electronic Data Analysis (EDA) tools for this type of analysis.