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In-Network and Out-of-Network Billing: Successful Claim Appeal Process

Session Information:
By: Kate Gilman, CPC, CPCO
Format: On-Demand Webinar
Duration of the training: 60 Minutes

Conference Material (Password Required)

The goal of this presentation is to understand the meaning of being in-network and out-of-network with payers; review the life of the claim; review what the appeal process means, review claim appeal guidelines and requirements, review what attachments are needed for the appeal, and how to set protocols for successful follow-up of denied claims for in and out of network providers.

Learning Objective:
  • To review what is in and out of network billing.
  • To review In and out-of-network requirements.
  • To review federal plan requirements for out-of-network providers.
  • To review the life of the claim.
  • To review what the appeal process means.
  • To review the appeal process for in and out-of-network providers.
  • To understand the timing of when an appeal is appropriate.
  • To understand what attachments are needed for appeal.
  • To discuss ways how to set protocols for successful follow-up of denied claims for in and out-of-network providers.
Areas Covered in the Session:
  • In and out of network billing rules and requirements
  • The appeal process for in and out-of-network providers.
  • When and how to Appeal
  • Documents required for the appeal.
  • Setting protocols for successful follow-up of denied claims for in and out-of-network providers.
  • What is In-Network Billing
  • What is Out-of-Network Billing
  • In and Out-of-Network Requirements
  • Commercial Payer Out-of-Network Policies and Products
  • Federal Plans Requirements for Out-of-Network
  • Medicare Advantage & Medicaid MCO
  • Dos and don’ts about being Out-of-Network
  • Examples of In-Network Reimbursement
  • Examples of Out-of-Network Reimbursement
  • Possible benefits of going Out-of-Network
  • Examples and general guidelines to state regulations for Out-of-Network and balance billing
  • No Surprises Act
  • No Surprises Act: good faith estimate
  • Life of the claim: Revenue Cycle Management
  • Denials and how do we deal with them?
  • Appeal process
  • Appeal rights for in and out-of-network providers
  • How to appeal?
  • Appeal example: Medicare
  • Appeal example: Medicare 2nd level
  • Medicare Appeal: Process Summary
  • Appeal example: AETNA
  • Appeal example: BCBS (Blue Cross Blue Shield Association) of MD
  • Appeal example: CIGNA
  • Appeal example: UHC (United HealthCare)
  • Appeal attachments
  • Ways How to be Proactive
  • How to have better control of your practice?
Suggested Attendees:
  • Medical providers, who are involved in the payment process of their practice
  • Physicians
  • Practice Managers
  • Billing Managers
  • C-level executives
  • Office managers
  • Medical billers
  • Medical Coders
  • Office staff and Billing Managers
  • Medical Billing Companies
  • Providers’ Office Staff
  • Hospital Revenue Cycle Staff
Presenter Headshot and Biography:

Kate has almost two decades of experience in the healthcare industry. She is an expert coder, and compliance officer, and trains healthcare providers all over the country. Kate utilizes her expertise to uncover ways to improve billing and coding inefficiencies, train staff, and ensure compliance while achieving maximum results and revenues for her clients.

Kate’s successes include small and large practices, ranging from primary care to specialists and surgeons. She is known for helping providers feel confident in their coding and have peace of mind with their compliance practices.

Kate’s acute attention to detail, deep understanding of coding and billing, and proactive approach make her an indispensable asset to all her clients.

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