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<div class="item">CMS & Commercial Payer Audit Risks & Targets: SIUs and MAC Audits</div>
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<h1 class="product-top-header" itemprop="name" title="CMS & Commercial Payer Audit Risks & Targets: SIUs and MAC Audits">
CMS & Commercial Payer Audit Risks & Targets: SIUs and MAC Audits
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<table style="border: none; border-collapse: collapse; width: 100%;">
<tbody>
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<td style="border-collapse: collapse; padding-left: 5px;"><strong>Format:</strong></td>
<td style="border-collapse: collapse; padding-left: 5px;"><strong>On-Demand</strong></td>
</tr>
<tr style="border-collapse: collapse;">
<td style="border-collapse: collapse; padding-left: 5px;"><strong>Presenter:</strong></td>
<td style="border-collapse: collapse; padding-left: 5px;"><strong>Eric C. Boughman</strong></td>
</tr>
<tr style="border-collapse: collapse;">
<td style="border-collapse: collapse; padding-left: 5px;"><strong>Duration:</strong></td>
<td style="border-collapse: collapse; padding-left: 5px;"><strong>60 minutes</strong></td>
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<p><span style="text-decoration: underline;"><a title="Lifetime Access After Successful Receipt" href="https://docs.google.com/forms/d/e/1FAIpQLScD8O0ZSqCy2CKObaAce4K22_N56P_xvEqPOtqRBEt7Z_MMNg/viewform?usp=sf_link" target="_blank" rel="noopener"><strong style="color: blue;">Conference Material (Password Required)</strong></a></span></p>
<hr>
<p style="background-color: #e4eaf1; padding: 10px; border-radius: 5px; margin-bottom: 10px;"><strong>Course Description</strong></p>
<p style="text-align: justify;">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.<br><br>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.<br><br>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.<br><br>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.<br><br>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.<br><br>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.<br><br>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.</p>
<p style="background-color: #e4eaf1; padding: 10px; border-radius: 5px; margin-top: 10px; margin-bottom: 10px;"><strong>Learning Objective</strong></p>
<ul>
<li style="text-align: justify;">Knowing the background of healthcare payment and reimbursement</li>
<li style="text-align: justify;">Identifying the payment and delivery systems</li>
<li style="text-align: justify;">Identifying public and private payors</li>
<li style="text-align: justify;">Knowing alternative payment models and options</li>
<li style="text-align: justify;">Understanding ex post facto laws</li>
<li style="text-align: justify;">Knowing SIUs, contractors and MACs</li>
<li style="text-align: justify;">Knowing contract/governing documents and policies</li>
<li style="text-align: justify;">Understanding the medical record review</li>
<li style="text-align: justify;">Knowing credentials of reviewers</li>
<li style="text-align: justify;">Understanding credential files</li>
<li style="text-align: justify;">Understanding signature requirements</li>
<li style="text-align: justify;">Understanding medical necessity</li>
<li style="text-align: justify;">Understanding treating physician rule</li>
<li style="text-align: justify;">Understanding the judgement error</li>
<li style="text-align: justify;">Understanding the audit process</li>
</ul>
<p style="background-color: #e4eaf1; padding: 10px; border-radius: 5px; margin-top: 10px; margin-bottom: 10px;"><strong>Areas Covered in the Session</strong></p>
<ul class="custom-ul">
<li>Background of healthcare payment and reimbursement</li>
<li>Payment and delivery system</li>
<li>Public and private payors</li>
<li>Alternative payment models and options</li>
<li>Ex post facto laws</li>
<li>SIUs, contractors and MACs</li>
<li>Medical record review</li>
<li>Credentials of reviewers</li>
<li>Credential files</li>
<li>Signature requirements</li>
<li>Medical necessity</li>
<li>Treating physician rule</li>
<li>Judgement error</li>
<li>Audit declaration</li>
<li>How did they find you?</li>
<li>Case study</li>
<li>Resources and tools</li>
</ul>
<p style="background-color: #e4eaf1; padding: 10px; border-radius: 5px; margin-top: 10px; margin-bottom: 10px;"><strong>Suggested Attendees</strong></p>
<ul class="custom-ul">
<li>Healthcare providers and staff.</li>
<li>Hospital and healthcare facility administration.</li>
<li>Vendors and contractors who work in the healthcare sector.</li>
<li>Legal counsel and other professional advisors to healthcare providers</li>
<li>Physician</li>
<li>Nurses</li>
<li>Physician Assistants</li>
<li>Healthcare Billing and Coding Staff</li>
<li>Credentialing and Enrollment Specialists</li>
<li>Healthcare Administrative Personnel</li>
<li>Clinic Managers</li>
<li>Credentialing and Enrollment Specialists</li>
<li>Healthcare Administrative Personnel</li>
<li>Practice Managers</li>
<li>Auditors</li>
<li>Compliance Officers</li>
<li>Medical record supervisors</li>
<li>Health Information Management Administrators and Technicians</li>
<li>Other Personnel Interested in Billing Privileges with the Medicare Program<br> </li>
</ul>
<p style="background-color: #e4eaf1; padding: 10px; border-radius: 5px; margin-top: 10px; margin-bottom: 10px;"><strong>About the Presenter</strong></p>
<p style="text-align: justify;">Eric Boughman is an AV-Rated Attorney and Certified Circuit Court Mediator whose law practice focuses on serving clients in the business of healthcare, technology, and other select industries. He relies on a diverse background to solve complex legal issues with a focus on compliance, risk management, and avoiding or reducing exposure from legal threats and lawsuits. His clients include businesses, professionals, investors, and entrepreneurs.<br><br>Eric spent the first decade of his career as a business litigator representing clients of all sizes, from Fortune 500 companies to local startups, in complex legal disputes. Over time, his experience and expertise grew, and Eric expanded his practice to provide a full range of comprehensive legal services, including regulatory, transactional, and general counsel for companies in the healthcare, technology, and med-tech space.<br><br>Eric particularly enjoys helping clients avoid legal troubles and aiding settlement among parties in dispute. The most rewarding components of his practice involve serving as a mediator (a neutral facilitator whose mission is to settle legal disputes) and general counsel services he provides for clients on a flat-fee basis.<br><br>Eric is a frequent writer and presenter on issues involving health law, privacy, technology, and asset protection. His writings have appeared in multiple American Bar Association publications, The Florida Bar Journal, Forbes, Daily Business Review, Accounting Today, Kiplinger, Financial Advisor Magazine, Law360, and CEO World, among others.<br><br>Eric is admitted to practice law in Florida and Nevada, as well as in the U.S. Tax Court, and in several other courts, nationwide, pro hac vice. He is active with local bar associations, including serving as an appointed member of his local jurisdiction’s grievance committee, and is also active in several charitable endeavors in his local community.</p>
<p style="background-color: #e4eaf1; padding: 10px; border-radius: 5px; margin-top: 10px; margin-bottom: 10px;"><strong>Additional Information</strong></p>
<p><strong>System Requirement</strong>:</p>
<ul>
<li>Internet Speed: Preferably above 1 MBPS</li>
<li>Headset: Any decent headset and microphone which can be used to hear clearly</li>
</ul>
<p>For more information you can reach out to the below contact: Toll-Free No: 1-302-444-0162 Email: <a href="mailto:care@skillacquire.com">care@skillacquire.com</a> </p></div></div>
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<div class="shipping"><%= model.shipping.label %></div>
<% } %>
<% if(model.handling_fee.amount) { %>
<div class="handle-fee"><%= model.handling_fee.label %></div>
<% } %>
<% if(model.setup_fee.amount) { %>
<div class="setup-fee"><%= model.setup_fee.label %></div>
<% } %>
<% if(model.tax.amount) { %>
<div class="tax"><%= model.tax.label %></div>
<% } %>
</div>
</div>
</div>
</div>
<div class="row total">
<div class="six wide mobile six wide tablet four wide computer column continue-column"></div>
<div class="six wide mobile six wide tablet eight wide computer column content-column">
<div class="ui grid">
<% if(model.setup_fee.amount) { %>
<div class="row">
<div class="six wide mobile four wide tablet six wide computer right aligned column">
<div class="title total-text">Total:</div>
</div>
<div class="six wide mobile eight wide tablet six wide computer right aligned column total-amount" id="total_amount">
<div class="title total">
<%= model.total %>
<% if (model.interval_short) { %>
<div class="subtitle">
<%= model.total_wo_setup_fee %> billed <%= model.interval %>ly
</div>
<% } %>
</div>
</div>
</div>
<% } else { %>
<div class="row">
<div class="six wide mobile four wide tablet six wide computer right aligned column">
<div class="title total-text">Total:</div>
</div>
<div class="six wide mobile eight wide tablet six wide computer right aligned column total-amount" id="total_amount">
<div class="title total">
<%= model.total %><% if (model.interval_short) { %>/<%= model.interval_short %><% } %>
</div>
</div>
</div>
<% } %>
</div>
</div>
</div>
<% if (model.interval) { %>
<div class="row right aligned">
<div class="ui divider"></div>
<div class="twelve wide column">
<p class="subscription-notice">
Note: Your subscription is automatically renewed unless cancelled during the subscription period.
</p>
</div>
</div>
<% } %>
</div>
</script>
<script class="template" type="text/template" id="shoppingCartSubTotalsView">
<div class="ui middle aligned grid subtotals-row">
<div class="row">
<div class="four wide column">
<h3 class="ui paragraph header"><span class="subtotal"><%= model.total %></span></h3>
</div>
<div class="eight wide right aligned column">
<a class="fr_primary_button centered checkout-button" href="<%= checkoutUrl %>">
Checkout
</a>
</div>
</div>
</div>
</script>
<script class="template" type="text/template" id="shoppingCartView">
<div class="ui segment content <%- model.interval ? 'subscription-checkout' : '' %>">
<div class="ui middle aligned checkout-items top grid">
<div class="row">
<div class="eight wide column">
<div class="header">
<h5 class="ui header">Items</h5>
</div>
</div>
<div class="two wide qty column">
<div class="header">
<h5 class="ui header">Qty</h5>
</div>
</div>
<div class="two wide price column">
<div class="header">
<h5 class="ui header">Price</h5>
</div>
</div>
</div>
</div>
<%= items %>
<div class="order-totals">
<%= totals %>
</div>
</div>
</script>
<script class="template" type="text/template" id="shoppingCartWidgetView">
<div class="ui segment content">
<div class="header">
<h5 class="ui header">Shopping cart</h5>
</div>
<%= items %>
<div class="order-totals">
<%= subtotals %>
</div>
</div>
</script>
<script class="template" type="text/template" id="shoppingCartEmbedView">
<div class="title overview-min">
<div class="ui grid">
<div class="eight wide column">
<a class="toggle-items">
<i class="icon dripicons-cart"></i>
<%- itemCount %> item<%- sellfy.helpers.pluralize(itemCount, '', 's') %>
<i class="icon dripicons-chevron-down"></i>
<i class="icon dripicons-chevron-up"></i>
</a>
</div>
<div class="right aligned four wide column total-min">
<strong>Total:</strong> <%= model.total %>
</div>
</div>
</div>
<div class="content <%- model.interval ? 'subscription-checkout' : '' %>">
<%= items %>
<div class="order-totals">
<%= totals %>
</div>
</div>
<% if(model.is_coupon_available){ %>
<form class="cart-form coupon-form">
<div class="discount-code-wrap">
<div class="ui fluid action tiny input discount-code">
<input type="text" name="discount_code" placeholder="Coupon code">
<button class="ui basic button apply-discount-code">Apply</button>
</div>
</div>
</form>
<% } %>
</script>
<script class="template" type="text/template" id="userLocationView">
<div class="user-location-container">
<div class="field country<%- !billing ? ' required' : ''%>">
<label for="<%- billing ? 'registration_country' : 'ship_country'%>">
<% if(billing) { %>
Country of registration
<% } else { %>
Country
<% } %>
</label>
<select id="<%- billing ? 'registration_country' : 'ship_country'%>" name="<%- billing ? 'company_details.registration_country' : 'shipping.address.country'%>" required>
<option value="" selected disabled>Please select...</option>
<% Object.entries(countries).forEach(([key, value]) => { %>
<option value="<%- key %>" <%-selected(currentCountry, key)%>>
<%- value.name %>
</option>
<% }) %>
</select>
</div>
<% if(!_.isEmpty(states) && !billing) { %>
<div class="field state<%- !billing ? ' required' : ''%>">
<label for="ship_state">State</label>
<select class="required" id="ship_state" name="shipping.address.state" required>
<option value="" selected="selected">Please select...</option>
<% Object.entries(states).forEach(([key, value]) => { %>
<option value="<%- key.split('-')[1] %>" <%-selected(currentState, key.split('-')[1])%>>
<%- value.name %>
</option>
<% }) %>
</select>
</div>
<% } %>
</div>
</script>
<script class="template" type="text/template" id="shippingInformationView">
<h5 class="ui header">Shipping information</h5>
<div class="one field">
<div class="field name required">
<label for="name">Full Name</label>
<input name="shipping.name" id="name" placeholder="John Doe" required value="<%- model.shipping.name %>">
</div>
</div>
<div class="two fields">
<div class="field line1 required">
<label for="ship_city">Street address</label>
<input name="shipping.address.line1" id="street1" placeholder="Wall Street" required autocomplete="street-address" value="<%- model.shipping.address.line1 %>">
</div>
<div class="field line2">
<label for="ship_city">Apartment, suite, etc.</label>
<input name="shipping.address.line2" id="street2" placeholder="5/25" value="<%- model.shipping.address.line2 %>">
</div>
</div>
<div class="one field">
<div class="field city required">
<label for="ship_city">City</label>
<input name="shipping.address.city" id="ship_city" placeholder="New York" autocomplete="address-level2" required value="<%- model.shipping.address.city %>" maxlength="32">
</div>
</div>
<div class="one field">
<div class="field postal_code required">
<label for="ship_postal_code">Postal / ZIP code</label>
<input name="shipping.address.postal_code" id="ship_postal_code" placeholder="10011" required autocomplete="postal-code" maxlength="10" value="<%- model.shipping.address.postal_code %>">
</div>
</div>
<div class="one field">
<div class="field phone required">
<label for="ship_phone">Phone number</label>
<input class="join" type="tel" name="shipping.address.phone" id="ship_phone" required placeholder="555-9876-123" autocomplete="tel" value="<%- model.shipping.address.phone %>">
</div>
</div>
</script>
<script class="template" type="text/template" id="billingInformationView">
<div class="one field billing-location"></div>
<div class="one field reg-number">
<div class="field vat-input">
<label for="vat_number_input">
<% if(sellfy.helpers.inEU(company_details.registration_country)) { %>
VAT number
<% } else { %>
Registration number
<% } %>
</label>
<input name="company_details.registration_number" class="set-form" placeholder="Registration number" type="text" id="vat_number_input" value="<%- company_details.registration_number %>">
<div class="ui pointing red basic label validation-error"></div>
</div>
</div>
<div class="one field">
<div class="field">
<label for="company_name">Company name</label>
<input name="company_details.company_name" autocomplete="organization" id="company_name" placeholder="Company name" value="<%- company_details.company_name %>" required>
</div>
</div>
<div class="one field">
<div class="field">
<label for="company_address">Company address</label>
<input name="company_details.address" placeholder="Company address" id="company_address" value="<%- company_details.address %>" required>
</div>
</div>
</script>
<script class="template" type="text/template" id="upsellApproveText">Adding...</script>
<script class="template" type="text/template" id="userPanel">
<div class="ui large circular black labels">
<% if(product_id) { %>
<a class="ui label customize" href="https://sellfy.com/user/products/<%- product_type %>/<%- product_id %>">
<i class="icon dripicons-gear"></i> Edit product
</a>
<% } else { %>
<a class="ui label customize" href="https://sellfy.com/user/store/edit/">
<i class="icon dripicons-toggles"></i> Customize
</a>
<% } %>
<a class="ui label" href="https://sellfy.com/user/dashboard">
<i class="icon-sellfy-logo"></i> Dashboard
</a>
</div>
</script>
<script class="template" type="text/template" id="upsellModal">
<form class="ui modal upsell-modal">
<i class="icon close"></i>
<div class="header">
<%- upsell.message %>
</div>
<div class="content">
<div class="product-card">
<div class="image-container">
<%= item.product.image.html %>
</div>
<h4 class="ui header name"><%- item.product.name %></h4>
<% if (item.discount.amount) { %>
<div class="price-old"><%= item.original_price.label %></div>
<% } %>
<% if (item.is_free) { %>
<h3 class="ui header price">FREE</h3>
<% } else { %>
<h3 class="ui header price"><%= item.adjusted_price.label %></h3>
<% } %>
</div>
<% if (item.product.variants && item.product.variants.length > 1) { %>
<div class="ui form product-variant">
<div class="field">
<label for="product_variant">Select variant:</label>
<select id="product_variant" name="variant">
<option selected disabled>
Please select...
</option>
<% item.product.variants.forEach(variant => { %>
<option value="<%- variant.id %>"
data-price="<%- variant.upsell_original_price.label %>"
data-total="<%- variant.upsell_adjusted_price.label %>"
data-image-html="<%- variant.image.html %>"
data-image-url="<%- variant.image.html %>"
data-outofstock="<%- variant.out_of_stock %>"
>
<%- variant.name %>
</option>
<% }); %>
</select>
</div>
</div>
<% } %>
</div>
<div class="actions">
<a class="fr_primary_button fr_large approve button <%- item.product.variants && item.product.variants.length > 1 || item.product.variants[0].out_of_stock ? 'ui disabled' : '' %>">
<% if(item.product.variants && item.product.variants[0].out_of_stock) { %>
Out of stock
<% } else { %>
Add to cart
<% } %>
</a>
<div class="cancel-action close">
<span>No thanks</span>
</div>
</div>
<input type="hidden" name="product" value="<%- item.product.key %>">
<input type="hidden" name="discount_id" value="<%- upsell.id %>">
</form>
</script>
<script class="template" type="text/template" id="proceedWithPaypalSubscriptionError">There has been an error processing your request. Please try again.</script>
<script class="template" type="text/template" id="paymentTypeNotSelectedError">Please select Payment type</script>
<script class="template" type="text/template" id="failedToSendMessageError">Failed sending message!</script>
<script class="template" type="text/template" id="fetchNextPageError">Error fetching next page.</script>
<script class="template" type="text/template" id="fetchNextPageErrorSuggestion">Please reload page and try again</script>
<script class="template" type="text/template" id="uploadFileError">Error uploading file.</script>
<script class="template" type="text/template" id="uploadImageError">Please use different format and try again or contact Sellfy support.</script>
<script class="template" type="text/template" id="defaultErrorHeader">Something went wrong...</script>
<script class="template" type="text/template" id="okButtonText">Ok</script>
<script class="template" type="text/template" id="defaultErrorBody">Something went wrong. Please reload page and try again</script>
<script class="template" type="text/template" id="paymentNotSuccessful">Payment was not successful</script>
<script class="template" type="text/template" id="addToCart">Add to cart</script>
<script class="template" type="text/template" id="outOfStock">Out of stock</script>
<script class="template" type="text/template" id="itemAdded">Item added!</script>
<script class="template" type="text/template" id="lowStock">Only {0} items left in stock.</script>
<script class="template" type="text/template" id="navDropdownItem">
<a class="item" href="<%- href %>" <%= rel ? 'rel=' + rel : '' %>>
<%= title%>
</a>
</script><script src="https://assets.sellfy.com/static/gen/packed_store_global.7bf85303.js"></script><div class="pswp" tabindex="-1" role="dialog" aria-hidden="true">
<div class="pswp__bg"></div>
<div class="pswp__scroll-wrap">
<div class="pswp__container">
<div class="pswp__item"></div>
<div class="pswp__item"></div>
<div class="pswp__item"></div>
</div>
<div class="pswp__ui pswp__ui--hidden">
<div class="pswp__top-bar">
<div class="pswp__counter"></div>
<button class="pswp__button pswp__button--close" title="Close (Esc)">
</button>
<div class="pswp__preloader">
<div class="pswp__preloader__icn">
<div class="pswp__preloader__cut">
<div class="pswp__preloader__donut"></div>
</div>
</div>
</div>
</div>
<button class="pswp__button pswp__button--arrow--left" title="Previous (arrow left)">
</button>
<button class="pswp__button pswp__button--arrow--right" title="Next (arrow right)">
</button>
</div>
</div>
</div>
<script class="template" type="text/template" id="productPageGalleryView">
<div class="carousel">
<div class="slides">
<% _.each(gallery.models, function(item, index){ %>
<div class="slide <%- index === 1 ? 'active' : '' %>" data-kind="<%- item.get('kind') %>">
<%= item.get('html') %>
</div>
<% }) %>
<% if(gallery.models.length > 1) { %>
<div class="control prev" data-action="prev">
<i class="icon dripicons-chevron-left"></i>
</div>
<div class="control next" data-action="next">
<i class="icon dripicons-chevron-right"></i>
</div>
<% } %>
<div class="control fullscreen" data-action="fullscreen">
<i class="icon dripicons-expand-2"></i>
</div>
</div>
<% if(gallery.length > 1) { %>
<div class="thumbnails">
<div class="rail">
<% _.each(gallery.models, function(item, index){ %>
<div class="gi thumbnail <%- index === 1 ? 'active' : '' %>" style="background-image:url(<%- item.get('url') %>)">
</div>
<% }); %>
</div>
</div>
<div class="ui divider"></div>
<% } %>
</div>
</script><script>
window.GLOBALS.PRODUCT_ID = '6360d627a3d5f0d49e07a923';
window.GLOBALS.PRODUCT_TYPE = 'physical';
</script>
<script type="text/javascript" src="https://assets.sellfy.com/static/gen/packed_productpage.663ab4b6.js"></script>
<script>
if (window._ga) {
ga('clientTracker.send', 'pageview');
}
</script>
</body></html>
