Effective Appeal Letter for Medical Claims Denials & Under-Reimbursement of Out-of-Network Claims


Original price was: $349.00.Current price is: $249.00.
Original price was: $399.00.Current price is: $251.00.
Original price was: $349.00.Current price is: $254.00.
Original price was: $349.00.Current price is: $255.00.

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
  • Understand Why a Claim Was Denied
  • Identify the Necessary Documents for a Successful Appeal
  • Know Your Appeal Rights (Including Under ERISA)
  • Health Plan Denial Responsibility Under ERISA
  • 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 – Medicare Low R&C Percentage
  • Recoupment Demands
  • Cross-Plan Offsetting
  • State Prompt Pay Laws
  • State Unfair Claim Settlement Practices
  • Appeals and Reconsiderations
  • No Surprises Act
  • Live Q&A Session
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:

Thomas J. Force, ESQ., is a state and federally licensed attorney with over 34 years of experience in the healthcare and insurance industries. As a former U.S. Marine and a successful Wall Street insurance litigator, Mr. Force served as General Counsel for a New York-based Accident and Health Insurance Company, where he also served as Chief Compliance Officer. These experiences led to the founding of The Patriot Group.

Mr. Force is a nationally recognized expert in revenue collection techniques, appeal strategies, and healthcare compliance. He is on the Advisory Board at Hunter Business School, a New York-based school for medical billing and coding students.

Mr. Force is an active member and frequent speaker on managed care and collection techniques for the Health Finance Management Association, several state medical associations, and other healthcare organizations.

On March 29th, 2022, Thomas J. Force, J.D, ESQ., President of The Patriot Group, served as moderator for the forum on Clinical Denial Management at Hofstra University, organized by the Health Finance Management Association – Metropolitan Section.

Additional Information:

After registration, You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.

System Requirement:
  • Internet Speed: Preferably above 1 MBPS
  • Headset: Any decent headset and microphone which can be used to talk and hear clearly
Can’t Listen Live?

No problem. You can get access to an On-Demand webinar. Use it as a training tool at your convenience. For more information, you can reach out to the below contact:
Toll-Free No: +1 800-757-9502
Email: cs@waymoreeducation.com