Medicare Appeal Process


Format: On-Demand Webinar
Duration of the training: 60 Minutes

The process for appealing Medicare payor denials can be lengthy and confusing. Join Sean as he walks through each level of the CMS Administrative Appeal process. Learn when it makes sense to file an appeal when the practice has received denials, what you need to be aware of when filing appeals and when you might need to call in a health care attorney.

Learning Objective:
  • Using the government and private payers guidance documents to stand your ground.
  • Understanding Statistical Sampling.
  • Understanding the various levels of appeal and what each might accomplish.
  • When to engage legal counsel and the importance of privilege.
  • Ways to minimize denials due to lack of medical necessity
  • Strategies to successfully appeal denied claims
Areas Covered in the Session:
  • Government and Private Payer Guidelines
  • Documents requirements for Successful Appeal Process
  • Privileging
  • Medical Necessity
  • Medicare Advantage
  • The 5 levels of Medicare appeals
  • What is meant by a Redetermination
  • What is meant by a Reconsideration
  • The Statistical Sampling Initiative and when it can be used
  • The requirements needed to request an ALJ hearing
  • Appeals Process
  • Appealing Medicare Decisions
  • Party and Non-Party Participation
  • Admission of New Evidence at the ALJ
  • Adjudication Time Frames and the Simplification of Escalation Provisions
  • The Eligible Claim Categories for the Statistical Sampling Initiative
  • Requirements for Statistical Sampling Initiative
  • Statistical Sampling Initiative Procedures
  • Challenges to Statistical Sampling
  • Filling an Appeal
  • The Medicare Appeal Process
  • The ALJ Process
  • Who’s Reviewing your Claims?
  • Carrier and Payor Denial Rates on Billed Claims for Services
  • Requesting a Redetermination
  • Requesting a Reconsideration
  • Reconsideration Decision Notification
  • Requesting an ALJ Hearing
  • Attorney Adjudicator
  • Calculating Amount in Controversy
  • OMHA Review of a Dismissal of a Reconsideration Request
  • OMHA Decision Notification
  • Appeal Council Review
  • Judicial Review in US District Court
Suggested Attendees:
  • Medical providers, who are involved in the payment process of their practice
  • C-level executives
  • Office staff and Billing Managers
  • Medical Billing Companies
  • Hospital Revenue Cycle Staff
  • Physician
  • Nurses
  • Physician Assistants
  • Nurse Practitioners
  • Medical Assistants
  • Practice Manager
  • Office Managers
  • Billers
  • Coders
  • Auditors
  • CDI Specialists
  • Collection Staff
  • Front Desk
  • IT Specialists
  • HIPAA Privacy and Security officers.
  • Compliance Officers
  • Telemedicine System Vendors
  • Patient Accounts Personnel
  • Medical record supervisors
  • Health Information Management Administrators and Technicians
  • Other Personnel Interested in Billing Privileges with the Medicare Program
Presenter Biography:

Sean has dedicated his career to serving and advocating on behalf of healthcare providers, hospital networks, and integrated health systems to ensure a level playing field and due process. Over the past 27 years, Sean has focused on helping organizations achieve measurable financial results to ensure stability in their market all while significantly reducing the risk of non-compliance. Sean’s knowledge of the inner workings of government agencies at both the state and federal level make him an invaluable asset to clients.

Sean leads the strategic litigation defense and audit team for DoctorsManagement, LLC. Sean is engaged by the largest and most revered law firms in the nation on matters tied to the False Claims Act and Health Care Fraud Statute cases to ensure the best possible defense for clients targeted by government agencies, their contractors, and commercial payer special investigative units.

Sean serves as a third-party Compliance Officer for numerous nationally recognized organizations across the country creating and ensuring a “Culture of Compliance” to mitigate risk and culpability.

Sean is a published author and the host of The Compliance Guy Podcast, the intersection where Compliance and the Business of Medicine meet… bringing to life regulatory compliance and health law-related issues, reaching tens of thousands of healthcare professionals weekly.

A sought-after healthcare speaker, Sean has an engaging, no-nonsense style and has delivered keynote addresses for countless professional societies and healthcare organizations. In his educational sessions, Sean presents workable solutions to the latest issues surrounding healthcare compliance, medical auditing, and practice and revenue cycle management. In May of 2021, Sean created The Compliance Guy Podcast©, bringing industry experts in the areas of operations, clinical, and legal together to ensure the highest level of learning and guidance to healthcare professionals.

Sean serves on boards of directors for both for-profit and non-profit organizations. He is a published author and a contributing author, and his written voice has reached tens of thousands of readers. His contributions to print and online publications (JAMA, Medical Economics, Part B News, BC Advantage, The Coding Edge, and MGMA Connections) cover a wide range of healthcare topics.