CourseAvenue Collections
Course Title: Health Plan - Benefit and Coverage Determination Consistency
Course Series: eComply Healthcare
Description:
Your organization likely has complex and well-conceived processes to define its benefit and medical coverage policies. This course examines the legal risks related to the rendering of benefit and coverage policy determinations that are inconsistent with internal policies. The focus is on the day-to-day processes of making benefit and coverage determinations in customer service, claims processing, member appeals and medical review functions.
This course helps you recognize factors that can cause inconsistent benefit and coverage determinations. Coverage determinations normally include clinical decision making and as a result, are often more complex and are a highly contested issue in the courts and in public policy. It is a responsibility of every employee to prevent, identify and correct issues that can result in inconsistent and inaccurate benefit and coverage determinations. It is crucial that your organization meet its obligations to its consumers in order to build more trusting relationships with consumers and to avoid high-profile, costly lawsuits.
At the completion of this course, you will be able to:
* Understand the difference between benefit and coverage determinations
* Identify the legal risks associated with making inconsistent benefit and coverage determinations
* Recognize potential issues leading to variation and inconsistencies in benefit and coverage determinations
* Analyze the controls around reducing variation in the process
* Report potential process issues that could result in inconsistencies
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