Navigating The Medicare Appeals Process

Event Materials (Key Required)

The process for appealing Medicare payor denials can be lengthy and confusing. Join the Compliance, Medicare Audit and Appeal Expert Sean M. Weiss, CHC, CMCO, CPMA, CMPE, CPC-P, CPC, CMOM, CMC, as he walks through each level of the CMS Administrative Appeal process. Learn when it makes sense to file an appeal when the practice has received denials, what you need to be aware of when filing appeals and when you might need to call in a health care attorney. When a beneficiary disagrees with a coverage or payment decision by Medicare, they have the right to file an appeal. Appeal process whether for original Medicare, Part D or Medicare Advantage can be daunting. Learn a step-by-step guide on when you are eligible to appeal a denial of service, the various deadlines, and tips for filing.

Learning Objectives:

• Using the government and private payers guidance documents to stand your ground
• Understanding Statistical Sampling
• Understanding the various levels of appeal and what each might accomplish
• When to engage legal counsel and the importance of privilege
• Ways to minimize denials due to lack of medical necessity
• Strategies to successfully appeal denied claims

Areas Covered in the Session:

• Government and Private Payer Guidelines
• Documents requirements for Successful Appeal Process
• Privileging
• Medical Necessity
• Medicare Advantage
• The 5 levels of Medicare appeals
• What is meant by a Redetermination
• What is meant by a Reconsideration
• The Statistical Sampling Initiative and when it can be used
• The requirements needed to request an ALJ hearing
• Appeals Process
• Appealing Medicare Decisions
• Party and Non-Party Participation
• Admission of New Evidence at the ALJ
• Adjudication Time Frames and the Simplification of Escalation Provisions
• The Eligible Claim Categories for the Statistical Sampling Initiative
• Requirements for Statistical Sampling Initiative
• Statistical Sampling Initiative Procedures
• Challenges to Statistical Sampling
• Filling an Appeal
• The Medicare Appeal Process
• The ALJ Process
• Who’s Reviewing your Claims?
• Carrier and Payor Denial Rates on Billed Claims for Services
• Requesting a Redetermination
• Requesting a Reconsideration
• Reconsideration Decision Notification
• Requesting an ALJ Hearing
• Attorney Adjudicator
• Calculating Amount in Controversy
• OMHA Review of a Dismissal of a Reconsideration Request
• OMHA Decision Notification
• Appeal Council Review
• Judicial Review in US District Court

Suggested Attendees:

• Medical providers, who are involved in the payment process of their practice
• C-level executives
• Office staff and Billing Managers
• Medical Billing Companies
• Hospital Revenue Cycle Staff
• Physician
• Nurses
• Physician Assistants
• Nurse Practitioners
• Medical Assistants
• Practice Manager
• Office Managers
• Billers
• Coders
• Auditors
• CDI Specialists
• Collection Staff
• Front Desk
• IT Specialists
• HIPAA Privacy and Security officers.
• Compliance Officers
• Telemedicine System Vendors
• Patient Accounts Personnel
• Medical record supervisors
• Health Information Management Administrators and Technicians
• Other Personnel Interested in Billing Privileges with the Medicare Program

Presenter Biography:

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Additional Information:

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to hear clearly

For more information, you can reach out to the below contact:
Toll-Free No: 1-302-444-0162
Email: care@skillacquire.com

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Snippet From Our Previous Session