How to Draft Appeal Letters: Boot Camp

Session 1 - Submitting A Bulletproof Claim

Speaker - Stephanie Thomas | Duration - 60 Min

What is a clean claim? As providers, coders, billers we are tasked with a job of getting claims out quickly, efficiently, and most importantly accurately. There are key points to be sure to check before submitting a claim to ensure proper processing. Also, things to watch during the submission phase passthrough to the payer. Payers have different processes, they change frequently, and we will go over the steps for the major commercial payers as well as Medicare Part B claim edits. Understanding their processes are 90% of the battle. 

Join this webinar by industry expert Stephanie Thomas to understand what process is needed for your claim we will show you how to work through issues, learn and set standard processes for the outcome you expect. By following this process, we teach in your practice you will watch your days in A/R drop, denials decrease and revenue sour-all while saving precious staff time.  

Webinar Objectives

• Importance of eligibility
• Proper follow up tools
• How to understand edits
• What to watch for in denials
• Getting patients involved in the process
• Process improvement

Webinar Agenda

• Missed revenue
• Increased denials and no follow through for appeal
• Practice management misuse or underuse of functionality
• Increasing over 60 accounts receivable
• Incorrect reimbursements
• Incorrect patient billing
• All of these issues will be addressed and how to prevent them in the future

Webinar Highlights

• Powerful claims
• Time management
• A/R control and increased revenue
• Working edits/denials fast
• Follow up process

Who Should Attend

• Medical office staff
• Administrators
• Office Managers
• Billing Staff
• Billing Managers
• Front desk staff
• Medical Assistants
• CNA’s

Session 2 - How to write an effective appeal letter and follow up for success

Speaker - Stephanie Thomas | Duration - 60 Min

Appeals are confusing. Appeals can seem impossible. Results may seem not worth the effort. In this webinar you will find useful tools and resources to understand the appeal process and how to turn your A/R around and get PAID for those claims after appeal.

Payers have different processes, they change frequently, and we will go over the steps for the major commercial payers as well as Medicare Part B Reopening, reconsideration, and appeals processing. Understanding the processes are 90% of the battle.

Once you understand what process is needed for your claim, our expert speaker Stephanie Thomas will show you how to write or verbalize your reason for appeal and the outcome you expect. Keywords in appeals are gold to getting good results and we will share these nuggets with our attendees.

Follow up is also key! Our speaker has created a bulletproof follow up process to be sure your claim is getting the attention it needs for proper payment. Squeaky wheel gets the grease!

Webinar Objectives

• How to write/verbalize appeal reason and expectation of outcome
• Proper follow up tools
• What to watch for in denials
• When to appeal and when to say “Uncle”
• Getting patients involved in the process
• Different payer appeal definitions and processes

Webinar Agenda

• Missed revenue
• Increased denials and no follow through for appeal
• Appeal misunderstanding
• Increasing over 60 accounts receivable
• Incorrect reimbursements
• Incorrect patient billing
• All of these issues will be addressed and how to prevent them in the future

Webinar Highlights

• Appeal success
• Time management
• A/R control and increased revenue
• Working Denials and when to appeal
• Follow up process.

Who Should Attend

• Medical office staff
• Administrators
• Office managers
• Billing staff
• Billing managers
• Front desk staff
• Medical assistants
• CNA’s

Session 3 - Denials Management

Speaker - Lynn M. Anderanin | Duration - 60 Min

Claim denials are an important part of the revenue cycle and a reason for low reimbursements. The first step of denials management is understanding the transaction codes sets that are used by insurance companies to deny claims and confirm that a denial is valid. Once a denial is found to be incorrect, it has to be appealed to show the denial was incorrect. This process can be set up to be streamlined to save time and resources. Organizing the process allows multiple staff to be involved so that staff strengths are used. This process will also assist in identifying trends when insurance companies have changed their policies or coding and billing staff are unaware that errors are being made.

Too often processing denials is put on the back burner to charge processing and payment posting. This webinar is going to look at the most common denials and give attendees valuable information on how to better manage denials so that reimbursement is not left on the table. Also this webinar will discuss methods of creating a process to ensure that timely filing limits are met and learn how tracking denials can assist in understanding changes in insurance carrier policies.   

Webinar Agenda

We will review the denial and remark codes of the most common denials and where these can be found as well as common claims edits that also code denials. We will walk through setting up a proven denials management process that includes recognizing trends in denials that can assist in seeing policy or coding changes that need to be implemented. When the denial is incorrect it is important to write an effective appeal for reimbursement and real examples will be shared

Webinar Highlights

• Finding and understanding denial and remark codes
• Common denials and how they will need to be reconciled
• NCCI policies that create denials
• Creating a denials management process based staff and technology
• Trending denials using your practice management system
• The appeals process
• Writing an effective appeal
• Knowing what to do when an appeal is not enough

Who Should Attend

• Reimbursement team
• Collectors
• Biller
• Coder
• Revenue cycle manager
• Administrator
• Cash poster

Session 4 - How to get payers to approve authorization requests quick!

Speaker - Stephanie Thomas | Duration - 60 Min

Pre authorizations is an important part of a medical practice. If you are seeing patients out of network, even more so! Commonly health care providers and practices are scrambling to find balance between time for patient care and the increasing administrative burden of prior authorizations and denials. On average, 14.6 hours per week is spent on pre authorizations and UM (utilization management), totalling more than $68,000 per year, per practice. Let us show you how to simplify this process and save valuable time for your staff and practice.

Some of the major insurance companies have extremely specific guidelines, being educated and confident of this up front will significantly increase your success rate. Provider cannot allow payers to determine how patients are treated, this webinar will allow your practice to take back that power and get authorizations and referrals upon first submission. Our expert speaker Stephanie Thomas will show your team tips on how to identify where to find payer specific guidelines and what to provide in requests to get better results from their hard work!

Make sure your entire care team attends this highly informative webinar, this will protect your bottom line.

Webinar Objectives

• Provide you with the knowledge of what payers are looking for!
• Help you to streamline internal processes.
• Guide you to appeal a denied authorization properly.
• Train you on how to identify areas of risk.
• Enable you to know the pros and cons of each type of preauthorization request.
• Make you feel confident about the documentation you are submitting for various authorization requests.
• Time Management, how to structure your day.
• Guide you on how to obtain correct information from patients so you have everything you need to request authorizations.
• Pros and cons of outsourcing this process.

Webinar Agenda

• Referrals and pre-authorization - details defined.
• Creating efficient workflow: Recommended items for workflow creation and approval success
• Obtaining correct info
• Insurance verification
• Organizing payer info
• Time management 
• Documentation recommendations 
• Dealing with external companies and auths
• Live rep authorizations
• How to appeal a denied authorization, Denial trends
• Utilizing online portals
• To outsource or not

Webinar Highlights

• Payer guidelines and processes
• How to appeal a denied authorization
• How to organize information to best deliver to payer
• Importance of insurance verification 
• Efficiency in workflow

Who Should Attend

• Medical office staff
• Administrators
• Office managers
• Pre authorization staff
• Billing staff
• Billing managers
• Front desk staff
• Medical assistants
• CNA’s

Session 5 - Out of Network-how to get pre authorizations or referrals to protect your bottom line

Speaker - Stephanie Thomas | Duration - 60 Min

Pre authorizations and referrals are one of the most important parts of your medical practice. If you are seeing patients out of network, even more so! Let us show you how to simplify this process and save valuable time for your staff and practice.

According to studies 76% say pre authorizations lead to patients stopping recommending treatments! We cannot allow payers to determine how patients are treated, this webinar will allow your practice to take back that power and get authorizations and referrals the first time. We will show your team tips on how to identify what payers are looking for and what to provide in requests to get better results from their hard work!

Make sure your entire care team attends this very informative webinar, this will protect your bottom line. Missed, denied or incorrect referrals or authorizations can be extremely detrimental for a medical practice. These errors or oversights can cost your practice thousands of dollars and usually cannot be recovered. Let us help you put processes in place to NEVER miss or have another denied or missed payment for a procedure or visit. It IS possible!

Webinar Objectives

• Missed revenue for denied or absent authorizations/referrals
• Excessive work to try to get retro-authorizations/referrals
• Incorrect processes for auths/referrals
• Payer rules and regulations not known or being followed
• Denials of claims for coding issues on auths/referrals
• Incorrect payer auths (changed insurance)
• Referral visits running out
• Incorrect provider/facility authorized

Webinar Agenda

• Issues we see often
• Things we can control
• Areas to improve
• Tools for success
• Processes to implement

Webinar Highlights

• Patient information-be sure you have all the pieces of the puzzle
• Payer policies, how to decode
• Internal processes for success
• Follow up-OFTEN
• How to deal with denials

Who Should Attend

• Medical office staff
• Administrators
• Office managers
• Pre authorization staff
• Billing staff
• Billing managers
• Front desk staff
• Medical assistants
• Practitioners (MD, DO, PA, NP, CRNA, etc)

Session 6 - The Successful Clinical Appeal – A Guide for the reconsideration and Appeal of Medical Necessity Denials

Speaker - Thomas J. Force, Esq. | Duration - 60 Min

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:

• How to distinguish a “clinical” denial from an “administrative” or technical denial, and why this is important;
• How to recognize a deficient or defective denial or “adverse benefit determination”;
• How to frame a demand to a health insurer or plan for the information that you require in order to prepare and submit an appeal or reconsideration request that reasonably is likely to succeed in a reversal of the denial; 
• What to do if the insurer or plan fails or refuses to provide you with the detailed factual information you need;
• What different appeal processes apply to clinical denials of Medicare, Managed Medicare (Medicare Advantage); Medicaid and state regulated commercial health plans, and the particularly complex appeal processes of denials issued by the administrators of self-funded health plans subject exclusively to ERISA;
• How to find out what standards of clinical review are properly to be applied by the insurer, plan or ERISA plan administrator; 
• Whether the provider should – or even can – “balance bill” the patient if at the conclusion of the appeal the denial is sustained.

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.

Webinar Objectives

This webinar will address the following areas of concern:

• Whether the denial notice or “adverse determination” is addressed to a clinical or an administrative (technical) ground;
• How and why is the notice defective?
• What the provider needs from the plan in order to frame a relevant appeal;
• How the provider makes demand on the plan for the specific factual information it needs to frame a meritorious and relevant appeal;
• What a successful demand should contain;
• Legal standing of the provider to file an appeal
• The appeals process, how it works, and how it differs depending on the different regulations that govern state regulated and federally regulated plans and products
• The additional requirements of any “in network” contracts that may apply;
• Just what standards of clinical review benefits does a health plan offer and whether the plan or administrator is properly applying those benefits to your claim;
• “Balance Billing”;
• “To Litigate or Not to Litigate”
• Potential “pitfalls” and useful practical suggestions.

Webinar Agenda

• Understanding the concepts
• Is it really a clinical denial ?
• Is the denial notice or adverse benefit determination legally and factually sufficient?
• Is the health plan fully insured or self-funded and why this is critical?  
• Getting what you need to know what to appeal
• Can you even appeal in the first place?
• What appeal process applies?
• The substance of the appeal
• ERISA plan administrators altering plan benefits 
• Litigation
• Denials and “Balance Billing” in the age of patient protection legislation

Webinar Highlights

• Making sure at the time that services are rendered that you will have the authority to appeal any denial of the claim 
• Rules and regulations to cite to the plan when demanding a proper denial notice
• The importance of distinguishing between federally regulated and state regulated health plans and insurers
• Litigation practice hints
• Whether you legally may “balance bill” the patient and the limitations of new state and federal legislation protecting patients from “surprise” and emergency bills.

Who Should Attend

• Hospital and Medical Group Case Managers
• Clinical Review Professionals
• the Billing Office Managers and Appeals/Reconsideration Staff of any Clinical Provider
• Employed and Retained Legal Counsel to Hospitals and Medical Groups