Learning Objectives

• 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

Suggested Attendees

• 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

About the Presenter