Learning Objectives

• Learn how to stop CIOX and others from large numbers of records requests and what the law says they cannot do
• Identify when the carriers (Including Medicare Advantage Plans) are lying about pre-auth and how to call them on it
• Address which law to quote to make the MA plans pay for everything that medicare part B pays for
• Stop MA plans from paying you less than they are required to by law
• How to report carriers & MA plans for denying claims without a full and fair review
• It is a violation of law to require documentation on all surgeries
• No more requiring pre-auth when pre-auth is not required
• Learn how to educate third party plans that their requests for records are illegal & how to quote the law to them
• Find out who to report to on medicare part C denying pre-authorizations
• Discover how MA plans are not allowed to make up their own rules
• See how to make MA plans honor the 1 year timely filing that the federal law requires them to honor
• Find out why your timely filing periods are not what you think they are
• Get a list of the 268 CPT/HCPCS codes covered under provisional and permanent telehealth status
• Learn how your fees might be reducing the medicare allowed amount on services you are billing for

Areas Covered in the Session

• When You Mark Accept Assignment on Claim Form
• Do Commercial Carriers Have to Send You the Checks If You Are OON (Out of Network)?
• Medicare Part C Plans: Reimbursement OON (Out of Network)
• Timely Filing Limit for Commercial Carriers
  • The Provider – Carrier Agreement
  • The Patient’s Policy
  • State Law
  • Federal Law
• Timely Filing Limit for Medicare Part C Plans
• For ERISA or PPACA Plans, What is the Minimum Appeal Period?
• Reimbursement for Out of Network with A Medicare Part C Plans
• When Can a Commercial Insurance Company Make the Doctor Refund Money Paid on A Claim?
• What is ERISA?
• Employment Compensation
• When is It an ERISA Claim?
• How Does ERISA Help with My Insurance Claims?
• Provider Agreements with The Carriers
• Patient’s Policy
• Carrier Requires Pre-Authorization When Pre-Authorization is Not Required Per the Policy
• Summary Plan Description (SPD)
• Language in Every SPD on Every Policy
• Recoupments
• Demanding Refund
• Who Can They Recoup From?
• What Can We Do If They Already Recouped?
• Carrier Time Limits on ERISA
• Managed Medicare Regulatory – OON Coverage Guidelines
• Managed Medicare Regulatory Guidelines – Prompt Payment
• Patient Protection and Affordable Care Act (PPACA) & Medicare Filing Time
• Payor Audit
• Medical Record Request Verify Compliance
• HIPAA – A Great Resource
• Medical Record Limitations
• Utilize HIPAA Protections
• HIPAA Disclosures and Healthcare Operations (MR Requests) – 45 CFR 164.501 & 164.506
• Receipt of Chart Audit Requests
• Medicare Advantage
• DOJ Monitoring MA Plans
• Medicare Advantage CMS Contact

Suggested Attendees

• Hospital CEOs, CFOs and COOs
• Medical Providers
• Administrators
• Office Managers
• Medical Billers
• Claims Coders
• Billing Staff and Companies
• Physicians and Other Providers
• Healthcare Consultants
• Compliance Officers
• Practice Manager
• In and Out of Network Providers
• Medical Billing Companies
• Providers Office Staff
• Hospitals and Facilities
• Insurance Companies
• Healthcare Attorneys

About the Presenter