Nursing CE Series: Medical Necessity--A Guide for Nurses and Case Managers
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Product Description:
Ensuring that your facility only bills for medically necessary services is a thorny problem for nurses and case managers. From the physician standpoint, a doctor may order any test he or she feels is necessary to appropriately diagnose and treat the patient. However, Medicare will only pay for those tests and services that meet the definitions of "medically necessary."
Often, determining the payer's definition of "medically necessary" is difficult. Federal and state payers and managed care organizations may have different definitions of medical necessity. They may also require different levels of diagnosis or treatment under their reimbursement rules.
Medical necessity—a guide for nurses and case managers will help you understand how your facility can meet Medicare's medical necessity guidelines. It will also help you learn to decode local medical review policies (LMRP), use advance beneficiary notices (ABN), and find other ways to comply with complicated medicare regulations.
Upon completion of this course the learner will be able to:
- Define medical necessity
- Identify what Medicare covers
- Identify who enforces the medical necessity rules
- Discuss why CMS issues national coverage decisions
- Identify guidelines for creating LMRPs
- Discuss how and when to use an ABN
- Recognize when a provider can bill without an ABN
- Describe what to do if a patient refuses to sign an ABN
- Identify three strategies to help your facility comply with Medicare regulations
Plus, you'll have the opportunity to earn one nursing contact hour!
Accreditation Statement:
HCPro, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
This course is pending approval by the Commission for Case Manager Certification (CCMC) for 2 (two) clock hours.
Take a look at some of the topics covered in Medical necessity—a guide for nurses and case managers:
Overview of medical necessity
Introduction
What is medical necessity?
Why should I care about medical necessity?
Why facilities avoid medical necessity
Introduction to the Medicare program
Why Medicare controls costs
What Medicare covers
CMS' role
Claims administrators
The role of program integrity contractors
Who enforces the medical necessity rules?
Case 1
National coverage decisions
Why CMS issues national coverage decisions
When CMS issues an NCD
What are CMS' choices?
CMS asks the experts
Steps CMS takes to issue a NCD
Understanding local rules
Introduction
"Pay it right"
Local medical review policies
Why do contractors create LMRPs?
Guidelines for creating LMRPs
How the public can get involved
LMRP updates
Learn to interpret LMRPs
Introduction
Contractor identification
Policy identification
Statutory and jurisdictional information
Policy effective dates
Service description
Service coding information
Diagnostic coverage and coding information
Reasons for noncoverage
Billing information
Record keeping and informational background
How to use advance beneficiary notices
Introduction
How Medicare protects beneficiaries
Beneficiary limitations on liability
When should providers obtain ABNs?
When providers can bill without an ABN
How to complete and deliver ABNs
Standardized ABN format
Medical emergency, duress, and EMTALA
What to do when patients won't sign the ABN
Prohibited ABN use
Case 2
Risks of not providing ABNs
How to help your facility comply
Perform medical necessity checks
Perform preservice checks
Review procedure codes
How to review diagnosis codes
What you need to know about ICD-9 codes
How to compare codes to LMRPs
Other times to perform preservice checks
How to perform postservice checks
Case 3
Case 4
This course is part of HCProfessor's Online Nursing CE Series. For more information on other courses in the series, click on the Online Learning section of this Web site. Or call Dave Miller toll free at 888/209-6554. You can even customize any online learning course to reflect your own policies and procedures.
Intended audience:
- Directors of nursing (DONs)
- Registered nurses (RN)
- Licensed practical nurse (LPN)
- Licensed vocational nurse (LVN)
- Nursing assistants (NA)
- Case managers
- Registration staff
- Clerical staff, medical records staff, patient accounting staff
- Billing and coding staff
- Radiology and laboratory staff
- All other ancillary staff in healthcare facilities
Benefits of Online Learning at www.hcprofessor.com include:
- Tough questions (and answers) about confusing regulatory standards
- Steps on how to solve pressing nursing needs
- Exam
- Instant test scores
- Case studies
- Test until success: The option of taking the exam as often as you need during password access
- Certificate of completion
- Student course history and documentation of training
- Discussion groups
- Note-taking and bookmark options
- Internet resources on guidelines and regulations
- Reference materials and recommendations on how to progress to the next step in your courses
Computer Requirements
- PC users must use Internet Explorer 4.0 or above
- MAC users must use Netscape Navigator 4.0 or above (the use of Internet Explorer may cause technical difficulties)
- Some courses and quizzes may require Adobe Acrobat Reader. To download Adobe Acrobat Reader, click here.
- Try our FREE DEMONSTRATION for both MAC and PC users
For full course descriptions, outlines, and special combination deals, go to www.hcprofessor.com.
Online learners will get 30-day access to the course materials and will be e-mailed their user name and password within 24 to 48 hours after payment has been received.
If you have questions, e-mail Customer Service or call 877/727-1728.
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