Unlock Untapped Revenue: Proven Appeal Tactics for In-Network and Out-of-Network Denied Claims

Out-of-Network and In-Network healthcare providers are now struggling to recover profits for their facilities and medical practices. This webinar will provide the audience with the steps and tool necessary to draft an effective appeal, discussing the defenses available and the documentation which should be submitted with the appeal. It will discuss the types of denial of claims from insurance companies and the best way to appeal each of them, including denials for lacking medical necessity, experimental or investigational, low pay, gap exceptions and coding issues.

This webinar will also discuss what a recoupment and audit is, the reasons that insurance companies state are the reasons for the overpayments and what steps should be taken to defend against the insurance company’s overpayment demands. The Webinar will address the ERISA obligations and protections and the importance of a provider obtaining a valid Assignment of Benefits. It will also set forth the notifications which must be sent out by the insurance company when it conducts an audit and seeks recoupment.

Learning Outcomes:

• Understand the Medical necessity denials
• Understand different types of denial – Experimental/ Investigational denials
• What is Bundled/ Inclusive denials
• Understanding the reason for the denial
• Know techniques designed to get denials reversed and low-reimbursed out-of-network claims reprocessed at higher reimbursement rates
• Instructions on how to draft an effective appeal including documents to enclose to ensure the appeal is processed and not rejected
• Interpreting the Explanation of Benefits and Plan terms
• Explaining the types of evidence necessary to support their right to payment
• Learn how to respond to an audit and refund demand by never refunding money without demanding a written explanation for the recoupment
• Know how to respond to a refund demand by verifying its accuracy
• Learn how to object to a recoupment in writing
• Learn how to make written ERISA Demands in objection letters
• Know what to do if the insurance company does not comply with ERISA demands
• Understand the time frames for seeking recoupment
• Learn about the importance of obtaining a valid and enforceable AOB

Areas Covered in the Session:

• Biggest Offenders & Most Common Complaints
  • Claims denied because MRS do not Support Services Billed
  • Claims denied for Medical Necessity/ Experimental/Investigational
  • Inclusive/Bundling
  • Retroactive denials and claw-backs
• Understand Why a Claim Was Denied
  • Lack of Medical Necessity
  • Experimental or Investigational
  • Not a Covered Service
  • Coding Issues
  • Not using an In-network Provider
  • Low payment based upon Medicare Rates (for OON Providers)
• Review EOB and/or Denial Letter
• Identify the Necessary Documents for a Successful Appeal
  • Summary Plan Description (SPD) and any applicable guidelines
  • Denial letter
  • Carrier-Specific DOR and AOB
  • Verification of Benefits form or transcript of Verification call
  • EOBs (Explanation of Benefits)
  • Claim Forms
  • Patient’s Insurance Card and Driver’s License
  • Pre-authorization Letters
  • Medical Necessity Letters and other Physician Opinion Letters
  • Medical Records
  • Coding Expert Report
  • Supporting published materials that may be utilized to support the procedure/product (studies, medical guidelines, portion of the SPD)
• Know Your Appeal Rights (Including Under ERISA)
• Health Plan Denial Responsibility Under ERISA
• More Ways to Appeals
  • State Prompt Payment Laws should be cited for ERISA-exempted plan
  • ERISA exemptions: Benefits plans provided by State or religious employers are not protected
  • State Unfair Claims Settlement Practices Act should be cited for ERISA-exempted plans
  • Consider Complaints to State Insurance Department when ERISA not applicable
  • Consider USDOL Complaints for ERISA plans
• Capture Payment on Medical Necessity Claim Denials
• Capture Payment on Coding-Based Claim Denials
• Appealing GAP Exception Request Denials
• Capture Payment on Low-Pay Claim Appeals
• Recoupment Demands
• Health Plan’s Special Investigation Unit (SIU)
• Cross- Plan Offsetting
• State Prompt Pay Laws
• State Unfair Claim Settlement Practices
• Appeals and Reconsiderations
• No Surprises Act

Recommended participants:

• In-Network and Out-of-Network Providers, Professionals and Facilities
• Healthcare Attorneys
• Medical Billing Staff
• Medical Coding and Documentation Staff
• Revenue Cycle Managers and Staff
• Claim Handling Team and Staff
• Healthcare Facility
• Practice Owners and Managers
• Billing Companies
• Insurance Companies
• Hospitals, Out-of-Network ASC’s
• Surgery Centers
• Medical Societies and Medical Associations

Presenter Biography: