It has been found that almost 100% of the prior authorization levels given by the Medicare Advantage Plans do not match the PDPM score calculated by the facility MDS. In many cases the difference is $200-$500 per day in reimbursement. NaviHealth is the approved vendor who authorizes SNF stays for Humana and Security Health Plan. In this session we will discuss the request for recalculation process and the financial ramifications.
- Identify the elements used by NaviHealth used to calculate a PDPM score.
- Describe the request for recalculation process versus the request for admitting diagnosis change
- List clinical documentation useful to the recalculation request.
- Define “transition” as it relates to NaviHealth authorizations
January 15, 2020
CEU: 1.0 – Data Structure, Content and Information Governance
Theresa Lang, RN, BSN, WCC
Theresa Lang, RN, BSN, WCC, is employed as the clinical reimbursement specialist for 9 SNFs in central and western WI. She has spent more than forty years working in long term care, consulting and training related to clinical reimbursement. She continues to have a consulting practice and train on ICD-10CM coding as an AHIMA approved ICD-10CM Trainer. Theresa is authoring a book on Diagnosis Coding and PDPM scheduled to be published in October 2019