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Two converging events are likely to produce a spike in Medicare outpatient claims denials: the implementation of a new CMS medical necessity edit system, and the end of transitional payments under the outpatient prospective payment system (OPPS).

Fiscal intermediaries implemented a line-item editing engine in OPPS in 2000. As a result, Medicare has become much more proficient at identifying claims for services that lack diagnosis codes considered medically necessary for a particular test or procedure, and are denying payment for them. These denials will become much more evident as the curtain drops on OPPS's "transitional corridor," which CMS used to cushion hospitals from the financial shock of changing from a cost-based to a prospective-payment system.

Outpatient prothrombin time (PT) tests, cardiology, magnesium policies and pulmonology are among the areas of high potential vulnerability to denials.

To minimize potentially grave reimbursement problems, hospital compliance and billing staff should redouble their efforts to prevent and correct avoidable medical-necessity denials.

Learn about specific steps hospital compliance and billing managers can take to implement a rigorous medical necessity compliance program as soon as possible. Spend 90 minutes with one of the nation's foremost authorities on the subject, Darren Carter, MD, President and CEO, of Provistas, a Manhattan-based medical coding consulting firm. Dr. Carter will set the stage with important background on:

Why medical necessity claims denials are likely to increase dramatically soon:

The majority of Dr. Carter's presentation features the details of:

Compliance initiatives hospitals can implement to minimize the impact:

Speaker

Benefit from the wisdom and guidance of one of the nation's leading authorities on Medicare coding and related compliance issues.

Darren Carter, MD, is President and CEO of Provistas, a Manhattan-based medical coding consulting firm. Dr. Carter has a personal commitment to alleviating medical coding uncertainties in the new health compliance environment. He founded Provistas to create comprehensive solutions to Medicare billing complexities, and brings nationally recognized expertise in Medicare policy analysis and software development to its services. Dr. Carter has authored dozens of articles, presented to professional and hospital associations, and serves on several editorial boards.

Moderator: Jill Brown, Managing Editor, Atlantic Information Services, Inc.

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Written Materials

Audiotape purchasers will receive highly useful written materials prepared by Dr. Carter that will track and supplement information presented during his 60-minute presentation.