The key to audit preparedness is developing a daily process for complying with the UR Standards of Medicare’s Conditions of Participation (CoPs). This session will provide insight into building and optimizing your UR Committee and process, ensuring an effective observation status and 1-day stay certification and appeal process that leverages case management, medical staff, and physician advisement expertise, and defending against Recovery Audit Contractor (RAC) medical necessity denials and potential False Claims Act (FCA) exposures. Attendees are also provided with a step-by-step approach to implement a consistent process that can not only ensure regulatory compliance but also create revenue integrity.

A strong physician advisement program is also a key to ensuring the strong hospital and medical staff communication necessary to manage evolving regulatory requirements. This session will provide insight into building and optimizing an internal compliance program that leverages Case Management expertise and Physician Advisement. It will examine how to create a UR process that proactively defends against RAC medical necessity denials. Attendees will gain an in-depth understanding of the rules for RACs, and the Administrative Law Judge appeal process. 

Learning objectives for this Webinar include:

• Deconstruct the alphabet soup. Understanding MACs, RACs, CERT , the 9th SOW, MMA, and FCA.
• Review the rules for RACs, the RAC review process, and the Administrative Law Judge appeal process.
• Discuss ways to establish consistent operational processes to ensure compliance in the event of 1-day stay reviews from the QIO.
• Learn how to unite the Medical Executive Committee and Administrative departments of your hospital to achieve a Medicare Admissions Review Program that meets CMS regulations.
• Learn how and why auditors including QIOs nationwide are targeting Short Stays and Observation Status.
• Learn how to evaluate your current compliance program and revenue risks in dealing with observation.

This session will provide attendees with 10 survival techniques to address the growing challenges hospitals face in protecting themselves from False Claims Act Actions based upon the lack of medical necessity, which has become a large focus of the OIG.

Who Should Attend

• Healthcare Provider CFO & CEO
• Chief Compliance Officer
• Compliance Director
• Chief Risk Officer
• Director of Risk Management
• Director of Regulatory Affairs
• Hospital Legal/Regulatory Counsel
• VP/Director of Revenue Cycle

About the Presenter

Dr. Ralph Wuebker, MD, MBA currently serves as Senior Medical Director for Executive Health Resources (EHR). Dr. Wuebker is Board Certified and continues to practice medicine a few days a month. He currently serves as a member of EHR’s physician education team and regularly visits EHR’s client hospitals to provide medical executives and staff members with ongoing education on a variety of topics including Medicare and Medicaid compliance and regulations, medical necessity, Recovery Audit Contractors, utilization review, denials management and length of stay.

Prior to joining EHR, Dr. Wuebker served as Medical Director for the Midwest Region of Great-West Healthcare (now a part of Cigna) where he was responsible for case reviews for medical necessity. Throughout his career, Dr. Wuebker has served as a practicing pediatrician, a pediatric hospitalist, and an instructor of pediatric medicine for Washington University School of Medicine and St. Louis Children’s Hospital. Dr. Wuebker earned his master of business administration degree from the Olin School of Business at Washington University in St. Louis, Mo., and his medical degree and a bachelor’s degree in biology from the University of Missouri-Kansas City School of Medicine.