This webinar will provide the audience with the steps and tool necessary to draft an effective appeal, discussing the defenses available and the documentation which should be submitted with the appeal. It will discuss the types of denial of claims from insurance companies and the best way to appeal each of them, including denials for lacking medical necessity, experimental or investigational, low pay, gap exceptions and coding issues.
This webinar will also discuss what a recoupment and audit is, the reasons that insurance companies state are the reasons for the overpayments and what steps should be taken to defend against the insurance company’s overpayment demands. The Webinar will address the ERISA obligations and protections and the importance of a provider obtaining a valid Assignment of Benefits. It will also set forth the notifications which must be sent out by the insurance company when it conducts an audit and seeks recoupment.
- Understanding the reason for the denial
- Interpreting the Explanation of Benefits and Plan terms
- Explaining the types of evidence necessary to support their right to payment
- How to respond to an audit and refund demand by never refunding money without demanding a written explanation for the recoupment
- How to respond to a refund demand by verifying its accuracy
- Participants will learn how to object to a recoupment in writing
- Participants will learn how to make written ERISA Demands in objection letters
- What to do if the insurance company does not comply with ERISA demands
- Time frames for seeking recoupment
- Importance of obtaining a valid and enforceable AOB
Areas Covered in the Session:
- Why physicians and facilities have difficulties getting claims paid based on denials for lack of medical necessity
- No pay claims based on coding issues
- Low pay claims using erroneous methodologies like Medicare rates or low percentages of reasonable and customary rates
- Discussion of appeal rights
- Discussion of evidence necessary to have an appeal granted
- Appeals to obtain a gap exception
- ERISA rights and documents the provider is entitled to from the insurance company
- How to request an external appeal
- What information to include for the first level appeal
- How the second level appeal is different from the first level appeal
Who Should Attend:
- In-Network and Out-of-Network Practitioners and Facilities
- Office staff and Billing Managers
- Healthcare Attorneys
- Medical Billing Companies
- Billing and Coding Specialists
- Providers’ Office Staff
- Hospital Revenue Cycle Staff
About the Presenter:
Mr. Thomas J Force, ESQ., is nationally recognized as an expert in revenue collection techniques, managed care contracting and appeal strategies. As a state and federally licensed attorney in both New Jersey and New York, Mr. Force has over 30 years of experience in the healthcare and insurance industries. His success as a Wall Street insurance litigator and his tenure as General Counsel for a New York-based Accident and Health Insurance Company where he served as Chief Compliance Officer propelled the founding of The Patriot Group.
Mr. Force is the founder and president of The Patriot Group is a full service revenue recovery company that provides billing, collections, and follow-up services as well as assistance with managed care appeals, managed care contracting, credentialing and compliance.
Mr. Force remains an active member and frequent speaker on managed care and collection techniques for the Health Finance Management Association, the Suffolk County Bar Association, and other organizations.
A United States Marine, Mr. Force received the prestigious Meritorious Mast Award for Leadership in 1987. Mr. Force is also co-Chairman of the Health and Hospital Committee of the Suffolk County Bar Association. He is co-founder of the Healthcare Reimbursement Attorneys Network, a national association of attorneys that represent physicians and hospital clients. Mr. Force also works closely with the American Medical Association and various state Medical Associations.
You will receive an email with login information and handouts (presentation slides) that you can print and share to all participants at your location.
Operating System: Windows any version preferably above Windows Vista & Mac any version above OS X 10.6
Internet Speed: Preferably above 1 MBPS
Headset: Any decent headset and microphone which can be used to talk and hear clearly
Can’t Listen Live?
No problem. You can get access to On-Demand webinar. Use it as a training tool at your convenience.
For more information you can reach out to below contact:
Toll-Free No: 1-302-444-0162