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Medicare and Medicaid Appeal: 2024 CMS Rules and Regulatory Changes

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It’s a lot easier for your practice to win appeals and receive compensation. The CMS has made the Medicare Appeal process simple and faster by clearing its backlog. in the case of Medicare, and will immediately begin to process new claims. With a few easy changes to your appeal process, you can recover the substantial amount of reimbursement. The money’s yours, and you need to know how to take care of it. Changes to your appeal argument, regulatory support, and knowledge of how to interpret the decision on appeal can lead to lucrative results in a number of circumstances.

This course will outline how to appeal denied claims from federal payors more effectively and efficiently. Understanding the different levels of appeals, the development of a strategy for each case, and writing persuasive appeal letters. You will also master the nuances of submitting appeals, such as reopening, network status, and clinical and coding reviews. By the end of this course, you will improve your appeal process and have the tools to recover more revenue, by ensuring success by understanding that details matter when it comes to keeping your money. Expert Kelly will walk you through the exact steps of how and when to appeal claims, so you capture more of the reimbursement you deserve. She’ll give you the anatomy, verbiage, and policy details you need to create appeals that convince payers to pay up.

Learning Objectives:
  • Understand the Various Levels of Appeals within Medicare FFS, Medicare Advantage and Medicaid Plans
  • Develop an Appeal Strategy to Submit Appeals Timely and With Favorable Outcomes
  • Learn Best Practices Based on Contractor Types for Submission, Tracking, and Determinations
  • Know All the Medicare and Medicaid Appeal Nuances
  • Understand In-Network and Out-of-Network Claims
  • Master Precertification (or Prior Authorization) Appeals Tactics that Get Your Claims Approved
Areas Covered in the Session:
  • Why appeal?
  • Appeal Basics
  • Appeals Process
    • Medicare FFS
      • 5 levels of appeal
    • Medicare Advantage Plans (MAPs)
      • Differs based on In-Network/Out-of-Network status
    • Medicaid/MCOs
      • Varies by State
    • Commercial Plans
  • Medicare Appeal Process
    • Redetermination
    • Reconsideration
    • Administrative Law Judge
    • Medicare Appeals Council (MAC)
    • Federal District Court
  • Medicare Appeal Timeframes
  • Medicaid Appeals
  • Medicare Advantage Appeals
    • The Plan (Reconsideration)
    • The QIC or IRE Reconsiderations
    • Administrative Law Judge
  • Organization Determination
  • Adverse Initial Determination
  • Other things to consider
  • Arbitration
  • Challenges
  • Private Payors/Commercial Plans
    • In-Network and Out-of-Network providers
      • Bound to contract (In-Network)
      • Must follow the appeals process outlined by plan
      • Involve a healthcare attorney, if needed
  • Anatomy of an Appeal
    • Consider the denial reason
    • Apply policy guidelines, when applicable
    • Create a successful appeal template
    • Only submit what is applicable to your argument
    • Obtain addendums to the record when possible
    • Pay attention to timelines
  • Tips and Tricks
    • Initial claim determinations
    • Post-payment denials
    • QICs and ALJs are bound by National Coverage Determinations (NCDs), CMS Rulings and applicable laws and regulations
    • QICs and ALJs are NOT bound by Local Coverage Determinations (LCDs) or CMS Program Guidance but give substantial deference
    • ALJ Hearings
    • Tips – Medicare Advantage Plans (MAPs)
  • Final Thoughts
Suggested Attendees:
  • Healthcare CEOs
  • Healthcare CFOs
  • Healthcare COOs
  • 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
  • Compliance Officers
  • Telemedicine System Vendors
  • Patient Accounts Personnel
  • Medical Record Supervisors
  • Other Personnel Interested in Billing and Appeal
  • Health Information Management Administrators and Technicians
  • Medical Providers, Who are Involved in the Payment Process of their Practice
Presenter Biography:

Kelly S. Grahovac serves as the General Manager for The van Halem Group where she focuses on audits, compliance, education, and resolving complex issues for clients in the post-acute care space. Kelly has over 20 years of experience working at one of the nation’s leading Medicare contractors and with The van Halem Group and is a known lecturer in the HH&H and HME industry, speaking at national conferences, state associations, and for private events. In addition, Kelly is a common contributor to a variety of industry publications and serves as a board member for both the South Carolina Medical Equipment Suppliers Association (SCMESA) and Big Sky Association for Medical Equipment Suppliers (AMES). Kelly also serves on the National Supplier Clearinghouse Advisory Committee (NSCAC).


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


Purchase Order Form – Click Here to download PO form.


Snippet From Our Previous Session

Frequently Asked Questions:

HOW MUCH TIME DOES IT TAKE TO RECEIVE THE DVDs/ FLASH DRIVE? +

For DVDs/ FLASH DRIVE – It will take around 7 working days.

CAN I PLACE AN ORDER ON CALL? +

Yes, you can call our toll-free number 302-444-0162 and ask our representative for the enrollment. Alternatively, you can also mail us at care@skillacquire.com.

CAN I PURCHASE ANY OF YOUR TRAINING FORMATS, AT ANY TIME? +

For DVDs/ FLASH DRIVE – Yes, you can place the order at care@skillacquire.com using the order brochure or can call us at our toll-free number 302-444-0162.

DO I REQUIRE A COMPUTER FOR ATTENDING A LIVE COURSE? +

The system requirements are quite basic: OS: 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, in case of live course you can raise questions using a microphone.

HOW CAN I BECOME FACULTY AT SKILLACQUIRE? +

Please share your detailed CV with us and our team will screen the best faculty for the specific field.

HOW CAN I GET ACCESS TO THE LIVE TRAINING? +

You can access the live training using Joining Link or Dial-In Number. To get the joining link, you can click on the conference materials on the product description page, and enter your email address and password that you received in your email.

We will also send you the joining link or dial-in number to the registered email address 2-3 days prior to the live training. You can simply click the joining link to join the live training.

HOW CAN I MAKE A BULK PURCHASE? +

You can call our customer service department at 302-444-0162 and may also avail some discounts on the bulk orders.

WHAT’S THIS DIFFERENT FORMAT? +
  • Live (One Attendee) – Only 1 person will be able to join the webinar
  • Live (2 to 4 Attendees) – Upto 4 persons are allowed to join the webinar
  • Live (5 to 10 Attendees) – Upto 10 persons are allowed to join the webinar
  • On-Demand Recording (One Attendee) – Webinar recording link will be provided for a single attendee
  • On-Demand Recording (Multiple Attendees) – Webinar recording link will be provided that can access by more than one person
  • DVD – DVD will be shipped physically to the address provided
  • Flash Drive – Flash drive will be shipped physically to the address provided
  • Live + DVD – This allows you to attend live webinar plus you also get DVD shipped to the address provided
  • Replay + FLASH DRIVE – Allows you to get webinar recording link plus you also get DVD shipped to the address provided
  • Live + REPLAY + DVD – This allows you to attend live webinar plus you also get webinar recording to your email and DVD shipped to the address provided
WHAT CERTIFICATION DO I GET POST THE TRAINING? +

After successful completion of the training, you will be awarded the course completion certificate (on request). The certifications/ recertifications should be mentioned under the description of every course.

TESTIMONIALS

“This program on HIPAA did a great job providing actionable concepts in a way that updated our team and me, I now know how I will implement the concepts because I already did it in their online seminar, it was easy to ask questions from the speaker at the end of my 60 minutes course.”
Melissa Preston, Health Information Management Staff
“David Vaughn covered the material completely and I have a new understanding of when, where and why we need to use an ABN”
Sandie Fowler, Out of Network Billing Staff
“Great presentation. Able to do during the day. Timing was great.”
Tina Duffy, Compliance Officer

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