Course Description:

Out-of-Network and In-Network healthcare providers are now struggling to recover their hard earned money. This webinar will provide the steps and tool necessary to draft an effective appeal, discussing the defences available and the documentation which should be submitted with the appeal. It will discuss the types of denial of claims from insurance companies and the best way to appeal each of them, including denials for lacking medical necessity, experimental or investigational, low pay, gap exceptions and coding issues. This webinar will provide you 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 Objectives:

• 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
• Physician
• 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 
• Prior Authorization Staff