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Course Description

Providers have the right to appeal denied claims! Do you have a facility policy or protocol? A RAC audit could be just around the corner with the new RCS1 proposed payment reform.  Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions. This is grated through Section 1869 of the Social Security Act and 42 C.F.R. part 405 sub-part I. Here you can find the procedures for conducting appeals of claims in Original Medicare (Medicare Part A and Part B). Keep it simple and join us for this program where we will answer all your questions about addressing denied claims. There are five levels in the Medicare Part A and Part B appeals process. The third level is or Administrative Law Judge(ALJ) hearing is one of the most critical for the team to be familiar with. This course will allow your team to expand their knowledge of the Re-determination, Reconsideration, ALJ hearing and Medicare Appeals Council level of appeals. Strategies will be presented to facilitate the most positive outcomes. Is your team familiar with the Appeals Processing Manual? There are some critical elements to the appeals process that when overlooked will lead to disastrous penalties.

Medicare Fee for Service regulations are plentiful as set forth by the Centers for Medicare & Medicaid Service (CMS). The Office of Inspector General (OIG) recommends adjustments to CMS programs which often result in laws by which the skilled nursing facility proprietors must abide.  The Medicare appeals process serves as an important protection for providers. Since its 1976 establishment, OIG has been at the forefront of the Nation’s efforts to fight waste, fraud and abuse in Medicare and Medicaid. A majority of OIG’s resources goes toward the oversight of Medicare and Medicaid programs that represent a significant part of the Federal budget.  A nationwide network of audits, investigations, and evaluations results in timely information as well as cost-saving or policy recommendations for decision-makers and the public. The goal for providers is to stay off the radar for audits and conduct their business in an accurate and appropriate manner to obtain payments for services delivered.

In the event that a provider is subjected to audits which result in claim denials with monetary take backs, there is a program that allows providers to advocate for appeal of these denied claims. Determining if, when and how to approach the daunting appeals process are not simple operational task;. and will reveal many solutions to successfully appealing and preventing future claim denials. Areas discussed include When can an appeal be filed? Where are the guidelines for processing claim appeals? What is an Amount in Controversy and how it is  determined? How to approach appeal correspondence to an Administrative Law Judge (ALJ). An increasing number of appeals are being heard at the (ALJ) level of the appeal process. In addition, a large percentage of these appeals are reversed and payments made to appellants.

This course will highlight successful strategies for the interdisciplinary team to effectively address denials for single and multiple claims.  The process for claim appeals can be overwhelming and a lack of meticulousness can result in an organization being subject to expanded reviews and government directed investigations.  The program will allow operators, managers and elected facility officials responsible for processing claim denials to establish best practices for overturning Medicare claim denials.

Area Covered In The Session:

  • Denial Definitions
  • Appeal Process Strategy
  • Guiding the Team
  • Forming Compelling Appeal Statements
  • Administrative Law Judge (ALJ) Hearing Format
  • ALJ Testimony
  • Triumphant Conclusions

Learning Objectives:

At the conclusion of the session, participants will be able to:

  • Attendees will be able to state the definition of key appeal terms.
  • Leaders will be able to identify a plan for educating the team on preparing claims appeals.
  • Attendees will identify 5 essentials tasks for the SNF IDT team in appeal process.
  • Attendees will be able to articulate appeal statements
  • The learner will be able to identify 3 strategies to employ during the ALJ Hearing.
  • Attendees will be familiar with ALJ  testimony.

Target Audiences:

  • Administrators
  • Nurse Managers
  • Nursing Staff
  • Business Office Managers
  • MDS Coordinators
  • Social Service Department
  • Rehabilitation Directors
  • Therapy Professionals

About Our Speaker:

Elisa Bovee has been working in the healthcare environment advocating for patients through education and clinical guidance for over 20 years.  With a Masters degree in Occupational Therapy she has managed a national operations team performing audits and analysis across the US for skilled nursing and healthcare providers. Her expertise includes clinical solutions for treatment of patients with multiple complexities, Compliance Programs, Regulatory guidelines, development of Education programs,Reimbursement and skilled documentation for nursing and therapy professionals. Managing claims through the Contractor Request and Denial phases is Ms. Bovee’s forte. Elisa presents programs nationally targeting all interdisciplinary groups seeking guidance and clarity on a multitude of Regulatory and clinical topics. Elisa has written and contributed to articles for numerous national trade publications.


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