This webinar by industry expert and renowned attorney Thomas J. Force will educate and enlighten any professional engaged in almost any aspect of hospital and medical claims billing on the complexities of framing an appeal or reconsideration of the clinical denial of a health care claim. In today’s environment of health provider competition and aggressive health plan efforts to reduce provider compensation no hospital, medical group or even individual clinical provider can afford simply to walk away from a denial or “adverse benefit determination”. Yet all too often the notice, explanation of benefits or other communication from the insurer or health plan – or a retained third-party reviewer - is devoid of the specific factual grounds for the denial and instead is replete with conclusory statements such as, “service does not meet our medical necessity criteria”. A health plan acting in good faith must make a clinical determination of eligibility for payment from an actual examination of the facts, yet the failure of the plan to advise the provider, whether intentionally or deliberately, of the factual specifics denies the provider 1) information needed to determine whether an appeal is even warranted; 2) address the appeal to the specific grounds identified by the health plan; 3) rebut the findings of the health plan reviewer by pushing back with facts and details that are relevant to the denial; and 4) assure that the provider benefits from a full and fair review. Denial notices also often fail to advise of the procedure that the plan requires to even effect the appeal. The many different parts will vary depending upon whether the plan or product is state or federally regulated; whether the provider is “in network” or “out of network”; what your network contract specifically may require; the time within which an appeal is allowed, and a myriad of other details with which the failure of the provider to comply may be fatal. The participant also will take away an understanding of whether it even can legally appeal a denial (surprisingly, the answer sometimes is “no”); whether it is advisable to litigate the denial; and whether as a last resort the patient should be – or even legally may be – “balance billed”.
This program will help you identify the failings and shortcomings in the denial notice and how to secure the information you must have to frame a relevant and meaningful appeal. Among other things you will learn:
From this program you will take away the skills and tools necessary to understand the clinical denial, decide whether to appeal, and frame your meritorious appeal in a way that is most likely to succeed.
This webinar will address the following areas of concern:
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