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How to Outflank Capricious and Arbitrary Medical Necessity Guidelines from Payers

How to Outflank Capricious and Arbitrary Medical Necessity Guidelines from Payers webcast image

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Stop having your claims denied based on arbitrary and capricious guidelines that have been manipulated and distorted by payers seeking to protect their own self-serving interests.

Price: $229.00

Product Code: AR072120

Webcast Format*:

Description Biography

Providers are reporting that the criteria used by payers to deny legitimate claims for medical necessity are arbitrary and capricious. Rather than being used to support hospitalization, payers are misusing both MCG and InterQual guidelines for their own self-serving purposes. Moreover, payer modifications of those guidelines are impossible to evaluate and, in particular, modifications for medical necessity are opaque. In fact, MCG allows payers to modify their product with their own definitions of medical necessity. Compounding the problem: payers seldom provide explanations as to the proper use of those guidelines.

These national standards have a role to play, but there is another way to establish medical necessity that will succeed as proven by successful appeals as you will learn in this upcoming webcast.

During this RACmonitor webcast, Marvin Mitchell, director of Case Management and Social Work at San Gorgonio Memorial Hospital in Southern California and a member of the RACmonitor editorial board, will outline a strategy to "reverse engineer" both national standards with a "Totality of the Record" approach that incorporates clinical documentation integrity (CDI), utilization management (UM) and the entire revenue cycle team. He'll explain exactly what payers are doing by claiming to use the national standards and how hospitals can create a UM process and platform that is adapted to the current environment while addressing emerging methods used by payers to judge medical necessity on their own terms. You will learn that there is no need to slavishly and unswervingly adhere to "criteria" based standards that serve to harm hospitals' financial health in the process.

Why This is Relevant:

UM departments are forced by payers to see MCG and InterQual standards as incontrovertible, and at the same time payers misuse or modify these standards in ways that are opaque and misapply MCG and InterQual using the most extreme metrics.

Learning Objectives:

  • Understand what payers are doing to foil reasonable hospital UM decision making
  • Learn what the concept, "Totality of the Record," can do to set the course for new approaches
  • Learn when to rely on national standards, when to adapt them and when to reject them
  • Discover how one national standard can be used to refute the other standard
  • Learn the other "standard" when the national standards fail

Who Should Attend:

Case managers and case management directors, utilization management directors, managers and professionals; physician advisors, revenue cycle directors, managers and professionals, clinical documentation integrity professionals.

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