Medicare RAC Summit
Medicare RAC Summit
Medicare RAC Summit
Medicare RAC Summit
Medicare RAC Summit
Medicare RAC Summit



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Go to Agenda:
Preconference | Day 1


Agenda: Day II
Friday, July 22, 2016

7:00 am
Breakfast

Optional Networking Breakfast Table Discussions


Host: Betty B. Bibbins, MD, BSN, CHC, CI-CDI, CPEHR, CPHIT
Topic: Key terms to assist PAs in spotting documentation within the medical record that demonstrates severity of illness or the need for greater intensity of care

Host: Elizabeth Lamkin, MHA
Topic: The power of the Utilization Management Committee (UMC)
    • Learn how to run an effective UMC
    • Understand how to leverage the power of the UMC

Host: Jeannine Z. Engel, MD, FACP
Topic: Writing effective appeals

Host: Ronald Hirsch, MD, FACP, CHCQM
Topic: Add some PEPPER to your breakfast -- interpreting your hospital's report

Host: R. Phillip Baker, MD
Topic: Interaction with Case Management -- vital to success

Host: K. Cheyenne Santiago, RN
Topic: A roundtable breakfast with WPS GHA

Host: Michael Salvatore, MD, FACP, CHCQM
Topic: LOS strategies

Host: Maria Johar, MD
Topic: Review of a specific case study

Host: John Zelem, MD,
Topic: What are the Hazards of Copy and Pasting?

CLOSING PLENARY SESSION: DENIAL PREVENTION THROUGH
MANAGED CARE PAYER CHALLENGES WITH LESSONS LEARNED

8:00 am Welcome and Overview
Audience Response System Polling
Day Egusquiza
President, AR Systems, Inc., Twin Falls, ID (Chair)

    Speaker Bio

    Day Egusquiza is President of AR Systems, Inc. and brings over 30 years experience in health care reimbursement, hospital business office operations, contracting and compliance implementation. During her 20 years as Director of Revenue and Reimbursement at a community hospital in Idaho, she also was Director of a Physician Medical Management billing service, where she completed an integrated business office between a hospital and a large physician clinic. Her work includes providing guidance as a compliance & APC educator while providing operational insight on the revenue cycle impacts of RAC/Medicare Recovery Audit Contractors. Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance - both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, and is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. Attendees at HFMA's ANI rated her in the top 25% for each year she has presented, earning her the 'Distinguished Speaker' award.
    Presentation Material (Acrobat)
    Poll Results (Acrobat)
    Poll Results (Acrobat)
8:15 am Specific Denial Cases, Provider Involvement, and Plan of Attack -- Aetna, Humana, and United (Commercial Managed Care and Medicare Advantage) and MAC (Noridian) Pre-pay Probe Denials
Jennifer L. Bartlett, CPAR
Clinical Appeals & Denials Coordinator, Infirmary Health, Mobile, AL

    Speaker Bio

    Jennifer Bartlett has served at Infirmary Health for 17 years through her vast knowledge and expertise in patient access, revenue cycle, payor contracts, payor processes and denials management. In her current role, she draws from many years of extensive research and intensive study of payor practices and behaviors which has been instrumental in increasing the pressure on payors to maintain a greater level of accountability. Her expertise allows her to effectively manage all aspects and types of governmental post payment and prepayment clinical audits including RAC, KePro 2MN audits, MAC prepayment denials, Medicare Advantage and CERT audits. Jennifer is a member of the Cahaba GBA Provider Outreach and Education Advisory Board and serves on the Alabama Hospital Association RIC/RAC steering committee as an advocate for improvements and greater transparency in all clinical governmental audit programs.
    Presentation Material (Acrobat)
Jeannine Z. Engel, MD, FACP
Associate Professor of Medicine, Physician Advisor, Billing Compliance, University of Utah Health Sciences, Salt Lake City, UT

    Speaker Bio

    Jeannine Z.P. Engel, MD FACP is a General Internist and Associate Professor of Medicine at the University Of Utah School Of Medicine. She sees patients in Huntsman Cancer Institute's Acute Care Clinic, teaches in the Medical School and is the Physician Advisor to the Billing Compliance Office. Dr. Engel received her Medical Degree from the University of California, San Diego. She completed her Internal Medicine Residency and a Chief Resident year at Vanderbilt University in Nashville, TN. She served on the Vanderbilt faculty for 15 years prior to moving to Salt Lake City in 2010. She sits on several national committees through the Society of General Internal Medicine and The American College of Physicians. In her role at the university, she translates the clinical and regulatory worlds, represents the medical center in federal audits, delivers education to providers and engages in process improvement related to documentation and billing.
    Presentation Material (Acrobat)
Michael Salvatore, MD, FACP, CHCQM
Physician Advisor, Beebe Medical Center, Lewes, DE

    Speaker Bio

    Michael Salvatore, MD, FACP received his MD from the University of Arizona in 1977. His post-graduate training 1977 - 1982 was at Duke University. He practiced Critical Care Medicine for 30 years before becoming a full time PA at Beebe Healthcare in 2012. He has been married for 45 years and has 2 daughters. When not working as a PA, he is watching birds or walking the dog with his wife.
Howard Stein, DO, MHA
Associate Director of Medical Affairs & Physician Advisor Case Management, Centrastate Medical Center, Freehold, NJ

    Speaker Bio

    Howard A. Stein D.O. M.H.A. is the Associate Director of Medical Affairs and Physician Advisor at Centrastate Medical Center, Freehold, New Jersey. He is a board certified family physician who served as an Assistant Clinical Professor of Family Medicine at Robert Wood Johnson Medical School, New Brunswick, NJ and at the University of Medicine & Dentistry, Newark, NJ. He is board certified by the American Board of Quality Assurance & Utilization Review Physicians. Howard is an executive board member of the American College of Physician Advisors. Howard performs bioethics consultations and serves as a leader on the Readmissions Task Force. He served as a physician in the United States Air Force. He is married for 31 years with 5 children.
    Presentation Material (Acrobat)
9:00 am The New Art of War, Medicare Advantage Plans

Learning Objectives:
  1. Learn how to decrease denials from the Medicare Advantage Plans and who to contact.
  2. Learn what types of complaints to forward to CMS to get results.
R. Phillip Baker, MD
Physician Advisor for Clinical Excellence, Self Regional Healthcare, Greenwood, SC

    Speaker Bio

    After completing his residency at the University Of South Carolina School Of Medicine Dr. Baker was the founding and managing partner in Piedmont Physicians for Women an OB/GYN practice for 32 years. He has extensive background in managed care and contracting. Initially serving as a part time Physician Advisor doing mainly second level reviews took on the role as a full time Physician Advisor for clinical Excellence in 2014. Responsibilities include Medical Director for Case Management, Physician Champion for CDI and dealing with denials for Self Regional Healthcare a regional hospital in Greenwood, SC. He also serves on several committees including Co-Chair of the Finance Committee for My Health First an upstate South Carolina ACO as well as several committees at the South Carolina Hospital Association.
    Presentation Material (Acrobat)
9:30 am How to Do and When to Do Peer to Peer with the Payers

Learning Objectives:
  1. Learn when to use peer to peer and when not.
  2. Learn successful techniques for managing peer to peer, win or lose.
Jeannine Z. Engel, MD, FACP
Associate Professor of Medicine, Physician Advisor, Billing Compliance, University of Utah Health Sciences, Salt Lake City, UT

    Speaker Bio

    Jeannine Z.P. Engel, MD FACP is a General Internist and Associate Professor of Medicine at the University Of Utah School Of Medicine. She sees patients in Huntsman Cancer Institute's Acute Care Clinic, teaches in the Medical School and is the Physician Advisor to the Billing Compliance Office. Dr. Engel received her Medical Degree from the University of California, San Diego. She completed her Internal Medicine Residency and a Chief Resident year at Vanderbilt University in Nashville, TN. She served on the Vanderbilt faculty for 15 years prior to moving to Salt Lake City in 2010. She sits on several national committees through the Society of General Internal Medicine and The American College of Physicians. In her role at the university, she translates the clinical and regulatory worlds, represents the medical center in federal audits, delivers education to providers and engages in process improvement related to documentation and billing.
    Presentation Material (Acrobat)
Maria Johar, MD
System Physician Advisor and Medical Director, Promedica Health Network, Promedica Health System, Toledo, OH

    Speaker Bio

    Dr. Maria Johar is the System Physician Advisor at ProMedica Health System and Medical Director for the Promedica Health Network.

    ProMedica was acknowledged for being an integrated health system that serves more than 4.4 million patients across its 13 hospitals, four ambulatory surgery centers and more than 300 other facilities each year.

    She joined the Promedica family in Oct 2012. She comes with over fifteen years of experience in the fields Of Utilization Review, Quality, Appeals, Joint Commission, Clinical Documentation, Safety and Infection Control. She is trained in LEAN methodology for system improvements.

    Prior to working with ProMedica Health System, she worked with Mercy Health System, Lima memorial Health System and Liberty Medical Center. She has worked with Ohio State Medicaid board on several process improvement initiatives. She has worked as a private consultant to physician offices and Hospitals as well as writing a book called DRG Tools. She has recently been recognized with an " Inventor of the year " for a software solution that will help healthcare systems across the nation have compliant billing.

    She lives in Toledo with her husband, two boys and three dogs.

    She is sits on the Lucas county suicide prevention board, and is associated with the National Physician Advisors Association, national and state case management associations and the National Association of Healthcare Quality.
    Presentation Material (Acrobat)
Ronald J. Rejzer, MD, CHCQM-PHYADV
Senior Vice President and Chief Physician Advisor, Parkland Health & Hospital System; Past President, ACPA, Dallas, TX

    Speaker Bio

    Dr. Ronald J. Rejzer is a native of Northwest Pennsylvania and received his medical degree in 1980 from the Hahnemann Medical University in Philadelphia followed by a residency at the Medical College of Virginia/VCU in Family Medicine. Dr. Rejzer practiced full time Emergency Medicine in the Tidewater area of Virginia for over eighteen years and was Board Certified in both Family Medicine and Emergency Medicine. For the past 15 years, Dr. Rejzer has held various Physician Executive roles, including VPMA and Chief Medical Officer positions for several prominent healthcare organizations and Administrative Director for a large Mid-Atlantic Hospitalist management company. Additionally, Dr. Rejzer has served as a consultant for Hospitalist programs, Utilization Management development and Physician Advisor programs and participated on several hospital boards and was elected President of a local medical society in Virginia. He has participated in Physician Advisor roles either part time or fulltime, for over twelve years. He currently serves full time as the SVP, Chief Physician Advisor at Parkland Hospital in Dallas, Tx, overseeing case management, utilization management, appeals and denials, and coding documentation improvement initiatives. As a founding member of ACPA, Dr. Rejzer served as the President of the American College of Physician Advisors, Inc. from 2014-2016. Dr. Rejzer is also a Diplomat of the ABQAURP with a subspecialty certification as a Physician Advisor.
    Presentation Material (Acrobat)
Michael Salvatore, MD, FACP, CHCQM
Physician Advisor, Beebe Medical Center, Lewes, DE

    Speaker Bio

    Michael Salvatore, MD, FACP received his MD from the University of Arizona in 1977. His post-graduate training 1977 - 1982 was at Duke University. He practiced Critical Care Medicine for 30 years before becoming a full time PA at Beebe Healthcare in 2012. He has been married for 45 years and has 2 daughters. When not working as a PA, he is watching birds or walking the dog with his wife.
    Presentation Material (Acrobat)
10:00 am Drawing and Break
10:30 am Building an Internal Appeal Process with your Physician Advisor

Learning Objectives:
  1. Gain practical advice on developing an internal appeal program in conjunction with PAs.
  2. Learn how to achieve organizational cost savings by hiring nurse appeal writers to successfully defend denials.
Kim Frazier, DNP, MSN, RN, ACM
Manager of Utilization and Appeals, CaroMont Regional Medical Center; Adjunct Graduate Faculty, Blair School of Health, Queens University of Charlotte, Gastonia, NC

    Speaker Bio

    Dr. Frazier is a graduate of Presbyterian Hospital School of Nursing in Charlotte, NC. She went on to complete her BSN and MSN from Queens University of Charlotte and received her Doctor of Nursing Practice (DNP) from Gardner-Webb University in Boiling Springs, NC. She has been a nurse for 28 years in a variety of settings including Cardiovascular Recovery, SICU, Nursing Management and as a Nursing Director in a large Level I Trauma center in Charlotte, NC.

    The past 15 years have been spent in Case Management and Utilization Review. She is also adjunct faculty at Queens University of Charlotte, the Blair School of Health, Presbyterian School of Nursing. She currently is the Manager of Utilization Review and Appeals at CaroMont Regional Medical Center where she heads a team of 12 UR and Appeals staff and works with a fabulous Medical Director and Lead Physician Advisor and seven other physicians that help as PA's.
    Presentation Material (Acrobat)
11:00 am ALJ Mock Hearing
  • Internal preparatory work - UR
  • Internal preparatory work - PA
  • Internal preparatory work - legal
  • Presentation to the ALJ
  • The ALJ decision
  • De-briefing -- Do's and Don'ts
Jennifer L. Bartlett, CPAR
Clinical Appeals & Denials Coordinator, Infirmary Health, Mobile, AL

    Speaker Bio

    Jennifer Bartlett has served at Infirmary Health for 17 years through her vast knowledge and expertise in patient access, revenue cycle, payor contracts, payor processes and denials management. In her current role, she draws from many years of extensive research and intensive study of payor practices and behaviors which has been instrumental in increasing the pressure on payors to maintain a greater level of accountability. Her expertise allows her to effectively manage all aspects and types of governmental post payment and prepayment clinical audits including RAC, KePro 2MN audits, MAC prepayment denials, Medicare Advantage and CERT audits. Jennifer is a member of the Cahaba GBA Provider Outreach and Education Advisory Board and serves on the Alabama Hospital Association RIC/RAC steering committee as an advocate for improvements and greater transparency in all clinical governmental audit programs.
Jeannine Z. Engel, MD, FACP
Associate Professor of Medicine, Physician Advisor, Billing Compliance, University of Utah Health Sciences, Salt Lake City, UT

    Speaker Bio

    Jeannine Z.P. Engel, MD FACP is a General Internist and Associate Professor of Medicine at the University Of Utah School Of Medicine. She sees patients in Huntsman Cancer Institute's Acute Care Clinic, teaches in the Medical School and is the Physician Advisor to the Billing Compliance Office. Dr. Engel received her Medical Degree from the University of California, San Diego. She completed her Internal Medicine Residency and a Chief Resident year at Vanderbilt University in Nashville, TN. She served on the Vanderbilt faculty for 15 years prior to moving to Salt Lake City in 2010. She sits on several national committees through the Society of General Internal Medicine and The American College of Physicians. In her role at the university, she translates the clinical and regulatory worlds, represents the medical center in federal audits, delivers education to providers and engages in process improvement related to documentation and billing.
Jessica L. Gustafson, Esq.
Founding Shareholder, The Health Law Partners, Southfield, MI

    Speaker Bio

    Jessica L. Gustafson is a founding shareholder with The Health Law Partners, P.C. She graduated cum laude from Miami University in 2002. Ms. Gustafson graduated from Wayne State University Law School in 2005. While in law school, Ms. Gustafson served as a member of the Wayne Law Review Editorial Board as a Senior Articles Editor. She also served as a judicial intern to the Honorable Robert H. Cleland, United States District Court, Eastern District of Michigan.

    Ms. Gustafson practices in all areas of health care law and devotes a substantial portion of her practice to representing providers in the Recovery Audit Contractor ("RAC") and Medicare audit appeals process. She also regularly assists clients with compliance and reimbursement matters.

    Ms. Gustafson is a member of the American Health Lawyers Association, American Bar Association (Health Law Section) and Michigan Bar Association (Health Care Law Section). She currently serves as the Vice-Chair of the Physician Issues Interest Group for the ABA Health Law Section.
Maria Johar, MD
System Physician Advisor and Medical Director, Promedica Health Network, Promedica Health System, Toledo, OH

    Speaker Bio

    Dr. Maria Johar is the System Physician Advisor at ProMedica Health System and Medical Director for the Promedica Health Network.

    ProMedica was acknowledged for being an integrated health system that serves more than 4.4 million patients across its 13 hospitals, four ambulatory surgery centers and more than 300 other facilities each year.

    She joined the Promedica family in Oct 2012. She comes with over fifteen years of experience in the fields Of Utilization Review, Quality, Appeals, Joint Commission, Clinical Documentation, Safety and Infection Control. She is trained in LEAN methodology for system improvements.

    Prior to working with ProMedica Health System, she worked with Mercy Health System, Lima memorial Health System and Liberty Medical Center. She has worked with Ohio State Medicaid board on several process improvement initiatives. She has worked as a private consultant to physician offices and Hospitals as well as writing a book called DRG Tools. She has recently been recognized with an " Inventor of the year " for a software solution that will help healthcare systems across the nation have compliant billing.

    She lives in Toledo with her husband, two boys and three dogs.

    She is sits on the Lucas county suicide prevention board, and is associated with the National Physician Advisors Association, national and state case management associations and the National Association of Healthcare Quality.
    Presentation Material (Acrobat)
Abby Pendleton, Esq.
Founding Shareholder, The Health Law Partners, Southfield, MI

    Speaker Bio

    Abby Pendleton is a founding partner of The Health Law Partners, P.C. She graduated Magna Cum Laude from Wayne State University Law School in 1996 and is a member of the Order of the Coif. Ms. Pendleton was a member of the Wayne State Law Review and served on its editorial board as a Senior Articles Editor. While at Wayne State, she was a recipient of the American Jurisprudence Book Awards in Contracts and Criminal Law as well as the Deloitte and Touche LLP Award for her achievement in tax law.

    Ms. Pendleton has been practicing healthcare law since 1996. She regularly provides counsel to healthcare providers and organizations in a number of areas, including but not limited to: compliance, Recovery Audit Contractors ("RAC"), Medicare and other payor audits, fraud and abuse, reimbursement matters, and HIPAA Privacy and Security, and physician staff privilege and licensure matters. Ms. Pendleton also specializes in legal issues impacting billing and management companies, anesthesia and pain management providers, hospice providers and mental health agencies.

    Ms. Pendleton is a member of the State Bar of Michigan (Member, Health Care Law Section) and State Bar of New York (Member, Health Law Section); the American Bar Association; the American Health Lawyer's Association; the Health Care Compliance Association; the Medical Group Management Association and the Michigan Medical Group Management Association.
Bob Soltis
Author, How to Handle Your Medicare Hearing; Former ALJ, Office of Medicare Hearings and Appeals (OMHA), Cleveland, OH

    Speaker Bio

    A former administrative law judge (ALJ) who decided over 4,500 Medicare cases during eight years on the bench, Bob Soltis teaches Americans the art of persuasive presentations and how to handle Medicare hearings.

    Bob's administrative agency career began in 1971 when he was appointed an ex officio member of the Gary Redevelopment Commission. As a Deputy Coroner, he assisted with autopsies and testified at a murder trial. A steelworker's son, Bob served as a Navy Judge Advocate for five years before returning to administrative law.

    A member of the Jimmo Implementation Council and an instructor at the Appeal Academy's Top Gun Audit School, Bob is the author of How to Handle Your Medicare Hearing and here is his LinkedIn profile: http://www.linkedin.com/in/bobsoltis.
Ernie de los Santos
Founder & Faculty Chair, Appeal Academy, San Antonio, TX (Facilitator)

    Speaker Bio

    Ernie de los Santos is Faculty Chair and Founder of Appeal Academy, and the popular online talk show, "Finally Friday!", and TopGun Audit School. He writes regularly for Appeal Academy, and provides marketing strategy and lead generation for vendors and consultants. Before entering the healthcare industry in 2006, he spent over 20 years in research and development of marketing and production, working on projects for Fortune 100 corporations, including Coca-Cola, Kodak, and the International Olympic Committee. Before that, he spent 10 years in B2B sales and marketing for Sony and Panasonic. He holds a BA in Anthropology and Computer Science, and an MBA in Marketing.
    Presentation Material (Acrobat)
12:00 pm

Panel with Q&A

Day Egusquiza
President, AR Systems, Inc., Twin Falls, ID (Moderator)

    Speaker Bio

    Day Egusquiza is President of AR Systems, Inc. and brings over 30 years experience in health care reimbursement, hospital business office operations, contracting and compliance implementation. During her 20 years as Director of Revenue and Reimbursement at a community hospital in Idaho, she also was Director of a Physician Medical Management billing service, where she completed an integrated business office between a hospital and a large physician clinic. Her work includes providing guidance as a compliance & APC educator while providing operational insight on the revenue cycle impacts of RAC/Medicare Recovery Audit Contractors. Ms Egusquiza is a nationally recognized speaker on continuous quality improvement (CQI), benchmarking, redesigning, reimbursement systems and implementing an operational focus of compliance - both in hospitals and practices. She has been on the AAHAM National Advisory Council, HFMA National Advisory Council, and is a past President of the Idaho HFMA Chapter & recently received the Lifetime Achievement Award. Attendees at HFMA's ANI rated her in the top 25% for each year she has presented, earning her the 'Distinguished Speaker' award.
12:30 pm Final Wrap-Up

Go to Agenda:
Preconference | Day 1




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