Navigating The Medicare Appeals Process

Course Description:

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

About the Presenter:

Sean has dedicated his career to serving and advocating on behalf of healthcare providers, hospital networks, and integrated health systems to ensure a level playing field and due process. Over the past 27 years, Sean has focused on helping organizations achieve measurable financial results to ensure stability in their market all while significantly reducing the risk of non-compliance. Sean’s knowledge of the inner workings of government agencies at both the state and federal level make him an invaluable asset to clients.

Sean leads the strategic litigation defense and audit team for DoctorsManagement, LLC. Sean is engaged by the largest and most revered law firms in the nation on matters tied to the False Claims Act and Health Care Fraud Statute cases to ensure the best possible defense for clients targeted by government agencies, their contractors, and commercial payer special investigative units.

Sean serves as a third-party Compliance Officer for numerous nationally recognized organizations across the country creating and ensuring a "Culture of Compliance" to mitigate risk and culpability.

Sean is a published author and the host of The Compliance Guy Podcast, the intersection where Compliance and the Business of Medicine meet... bringing to life regulatory compliance and health law-related issues, reaching tens of thousands of healthcare professionals weekly.

A sought-after healthcare speaker, Sean has an engaging, no-nonsense style and has delivered keynote addresses for countless professional societies and healthcare organizations. In his educational sessions, Sean presents workable solutions to the latest issues surrounding healthcare compliance, medical auditing, and practice and revenue cycle management. In May of 2021, Sean created The Compliance Guy Podcast©, bringing industry experts in the areas of operations, clinical, and legal together to ensure the highest level of learning and guidance to healthcare professionals.

Sean serves on boards of directors for both for-profit and non-profit organizations. He is a published author and a contributing author, and his written voice has reached tens of thousands of readers. His contributions to print and online publications (JAMA, Medical Economics, Part B News, BC Advantage, The Coding Edge, and MGMA Connections) cover a wide range of healthcare topics.

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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