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DURATION: 60 MINUTES
SPEAKER NAME: THOMAS J. FORCE, ESQ.
Learn how to frame an appeal or reconsideration of the clinical denial of a health care claim.
This session by industry expert and renowned attorney Thomas J. Force will educate and enlighten any professional engaged in almost any aspect of hospital and medical claims billing on the complexities of framing an appeal or reconsideration of the clinical denial of a health care claim. In today’s environment of health provider competition and aggressive health plan efforts to reduce provider compensation no hospital, medical group, or even individual clinical provider can afford simply to walk away from a denial or “adverse benefit determination”. Yet all too often the notice, explanation of benefits, or other communication from the insurer or health plan – or a retained third-party reviewer – is devoid of the specific factual grounds for the denial and instead is replete with conclusory statements such as, “service does not meet our medical necessity criteria”. A health plan acting in good faith must make a clinical determination of eligibility for payment from an actual examination of the facts, yet the failure of the plan to advise the provider, whether intentionally or deliberately, of the factual specifics denies the provider 1) information needed to determine whether an appeal is even warranted; 2) address the appeal to the specific grounds identified by the health plan; 3) rebut the findings of the health plan reviewer by pushing back with facts and details that are relevant to the denial; and 4) assure that the provider benefits from a full and fair review.
Denial notices also often fail to advise of the procedure that the plan requires to even effect the appeal. The many different parts will vary depending upon whether the plan or product is state or federally regulated; whether the provider is “in-network” or “out of network”; what your network contract specifically may require; the time within which an appeal is allowed, and a myriad of other details with which the failure of the provider to comply may be fatal. The participant also will take away an understanding of whether it even can legally appeal a denial (surprisingly, the answer sometimes is “no”); whether it is advisable to litigate the denial; and whether as a last resort the patient should be – or even legally maybe – “balance billed”.
This program will help you identify the failings and shortcomings in the denial notice and how to secure the information you must have to frame a relevant and meaningful appeal. Among other things you will learn:
DURATION: 60 MINUTES
SPEAKER NAME: STEPHANIE THOMAS
Pre-authorizations and referrals are some of the most important parts of your medical practice. If you are seeing patients out of network, even more so! Let us show you how to simplify this process and save valuable time for your staff and practice.
According to studies, 76% say pre-authorizations lead to patients stopping recommending treatments! We cannot allow payers to determine how patients are treated, this webinar will allow your practice to take back that power and get authorizations and referrals the first time. We will show your team tips on how to identify what payers are looking for and what to provide in requests to get better results from their hard work!
Make sure your entire care team attends this very informative webinar, this will protect your bottom line. Missed, denied or incorrect referrals or authorizations can be extremely detrimental for a medical practice. These errors or oversights can cost your practice thousands of dollars and usually cannot be recovered. Let us help you put processes in place to NEVER miss or have another denied or missed payment for a procedure or visit. It is possible!
Note: This is a combo of 2 Live Webinars (each with a 60-minute duration)
|Nov 04, 2021||Federal No Surprises Act – The IDR Process, Good Faith Estimates, and What Providers Need to Know||60 Mins||$199.00|
|Jun 24, 2021||An Effective Out-of-Network Workflow to Increase Reimbursement and Stay Compliant||60 Mins||$199.00|
|Apr 14, 2021||The Successful Clinical Appeal – A Guide for the reconsideration and Appeal of Medical Necessity Denials||60 Mins||$199.00|
|Mar 23, 2021||The New Federal No Surprise Act – Impact on Out-of-Network Providers||60 Mins||$199.00|
|Aug 20, 2020||Lessons Learned from the Cigna and Aetna cases against Humble Surgical Hospital||60 Mins||$199.00|
|Jun 16, 2020||How to Defend Against Insurance Company Recoupments, Repayment Demands, and SIU Audits||60 Mins||$199.00|