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How to Be Proactive After a Medical Denial

Learn how to respond to a denial adequately and professionally to increase your chances of a denial being overturned.

Medical denials come in various forms from the type of denial to the party making the adverse determination. When a medical provider receives a denial, it commonly includes limited reasoning justifying the denial and a summary of appeal rights afforded to contest the decision. However, even with the receipt of this information, the medical provider may not understand how this process works or how to present an adequate response to the denial. It prepares a submission that only responds to the initial basis of the medical denial not realizing an extended appeals process offers the party issuing the denial an opportunity to utilize other justifications for the adverse decision. It may not comprehend requirements as to how to submit evidence refuting the denial. Furthermore, a medical provider may not understand the long-term implications of failing to respond adequately to such a denial. One may overcome these issues by being proactive in addressing medical denials. This topic explains the medical denial appeals process and how one should proactively prepare their case to take advantage of the opportunities afforded to them. It will also describe in detail how to present a response to address the initial denial, how to proactively anticipate and circumvent in advance subsequent reasoning that may be used against the medical provider and ensure that a waiver of appeal rights does not occur. This information will assist those individuals responsible for responding to medical denials to develop and implement best practices by illustrating examples of approaches to take when creating standard operating procedures for responsive actions. Failure to do so may result in submission of insufficient evidence to support the medical provider's argument or even result in a waiver of a right one is guaranteed under law or by contract. This material is critical for medical providers to adequately approach, prepare and present their reasoning and evidence to support their argument that the medical denial should be overturned.

Runtime: 89 minutes
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Why Lorman?

Over 33 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Agenda

Introduction

  • What Is a Medical Denial?
  • When Are Appeal Rights Triggered?
  • How Should One Approach a Medical Denial?
  • Why Should I Appeal a Medical Denial?

Types of Medical Denials

  • Types of Payors
  • Coverage Decision vs. Appeal Decision
  • Due Process Concerns

The Proactive Approach to Building Your Case

  • Analyzing and Compiling a Response to an Adverse Decision
  • Recognize Who Is Reviewing Your Appeal
  • Compiling Responsive Evidence and How to Present the Case
  • The Question of Use of Expert Witnesses
  • Thinking Long Term Rather Than the Immediate Denial

Best Practices in Presenting Your Case

  • Methods to Format the Response
  • What Are the Limitations for the Response?
  • Does the Kiss (Keep It Short and Simple) Approach Work?
  • Waiver and How It Can Limit Your Appeal Rights
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Why Lorman?

Over 33 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Credits

MP3 Download

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

OnDemand Course

This course was last revised on August 20, 2020.

Call 1-866-352-9540 for further credit information.

  • AHIMA 1.5 including Data Structure, Content, and Information Governance 1.5
     
  • This program has been approved for 1.5 continuing education units for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.
     

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

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Why Lorman?

Over 33 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Faculty

Patrick D. Souter

Patrick D. Souter

Gray Reed & McGraw LLP

  • Of Counsel in the health care section of Gray Reed & McGraw LLP
  • Represents physician and physician groups, hospitals and ancillary health care providers providing in the facility, physician group and mobile delivery setting
  • Frequent speaker on operational issues encountered by health care providers such as fraud and abuse issues, including federal Stark Law, Anti-Kickback, False Claims and Travel Act statutes and similarly applied state laws, payor disputes including payor appeals and compliance matters
  • Author of numerous articles involving health care legal matters and co-author of Representing Physicians, 4th Ed., Physician Law Evolving Trends and Hot Topics (2017- 2019 Editions) and What is … Medical Staff Peer Review?
  • Adjunct Professor of health care studies, Baylor University School of Law and Baylor University, Hankamer School of Business Robbins Institute of Health Policy and Leadership
  • L.L.M. degree in health law, Hofstra University; J.D. degree, Baylor University; M.B.A. degree in health services management, University of Dallas; B.B.A. degree in finance, Baylor University
  • Can be contacted at 214-954-4135 or [email protected]
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Product ID: 407619
Published 2020
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