Medicare and Medicaid Appeal: 2024 CMS Rules and Regulatory Changes

Event Materials (Key Required)

Course Description

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
  • 5 levels of appeal
  • Differs based on In-Network/Out-of-Network status
  • Varies by State
• Medicare FFS
• Medicare Advantage Plans (MAPs)
• Medicaid/MCOs
• 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
  • Bound to contract (In-Network)
  • Must follow the appeals process outlined by plan
  • Involve a healthcare attorney, if needed
• In-Network and Out-of-Network providers  
• 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

About the Presenter

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. 

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