The Successful Clinical Appeal – A Guide for the reconsideration and Appeal of Medical Necessity Denials

April 14, 2021
60 Mins
Thomas J. Force, Esq.
 Add to Wishlist

This webinar by industry expert and renowned attorney Thomas J. Force will educate and enlighten any professional engaged in almost any aspect of hospital and medical claims billing on the complexities of framing an appeal or reconsideration of the clinical denial of a health care claim.  In today’s environment of health provider competition and aggressive health plan efforts to reduce provider compensation no hospital, medical group or even individual clinical provider can afford simply to walk away from a denial or “adverse benefit determination”.  Yet all too often the notice, explanation of benefits or other communication from the insurer or health plan – or a retained third-party reviewer - is devoid of the specific factual grounds for the denial and instead is replete with conclusory statements such as, “service does not meet our medical necessity criteria”.  A health plan acting in good faith must make a clinical determination of eligibility for payment from an actual examination of the facts, yet the failure of the plan to advise the provider, whether intentionally or deliberately, of the factual specifics denies the provider 1) information needed to determine whether an appeal is even warranted; 2) address the appeal to the specific grounds identified by the health plan; 3) rebut the findings of the health plan reviewer by pushing back with facts and details that are relevant to the denial; and 4) assure that the provider benefits from a full and fair review.  Denial notices also often fail to advise of the procedure that the plan requires to even effect the appeal.  The many different parts will vary depending upon whether the plan or product is state or federally regulated; whether the provider is “in network” or “out of network”; what your network contract specifically may require; the time within which an appeal is allowed, and a myriad of other details with which the failure of the provider to comply may be fatal.   The participant also will take away an understanding of whether it even can legally appeal a denial (surprisingly, the answer sometimes is “no”); whether it is advisable to litigate the denial; and whether as a last resort the patient should be – or even legally may be – “balance billed”.

This program will help you identify the failings and shortcomings in the denial notice and how to secure the information you must have to frame a relevant and meaningful appeal.  Among other things you will learn:

  • How to distinguish a “clinical” denial from an “administrative” or technical denial, and why this is important;
  • How to recognize a deficient or defective denial or “adverse benefit determination”;
  • How to frame a demand to a health insurer or plan for the information that you require in order to prepare and submit an appeal or reconsideration request that reasonably is likely to succeed in a reversal of the denial; 
  • What to do if the insurer or plan fails or refuses to provide you with the detailed factual information you need;
  • What different appeal processes apply to clinical denials of Medicare, Managed Medicare (Medicare Advantage); Medicaid and state regulated commercial health plans, and the particularly complex appeal processes of denials issued by the administrators of self-funded health plans subject exclusively to ERISA;
  • How to find out what standards of clinical review are properly to be applied by the insurer, plan or ERISA plan administrator; 
  • Whether the provider should – or even can – “balance bill” the patient if at the conclusion of the appeal the denial is sustained.

From this program you will take away the skills and tools necessary to understand the clinical denial, decide whether to appeal, and frame your meritorious appeal in a way that is most likely to succeed.

Webinar Objectives

This webinar will address the following areas of concern:

  • Whether the denial notice or “adverse determination” is addressed to a clinical or an administrative (technical) ground;
  • How and why is the notice defective?
  • What the provider needs from the plan in order to frame a relevant appeal;
  • How the provider makes demand on the plan for the specific factual information it needs to frame a meritorious and relevant appeal;
  • What a successful demand should contain;
  • Legal standing of the provider to file an appeal
  • The appeals process, how it works, and how it differs depending on the different regulations that govern state regulated and federally regulated plans and products
  • The additional requirements of any “in network” contracts that may apply;
  • Just what standards of clinical review benefits does a health plan offer and whether the plan or administrator is properly applying those benefits to your claim;
  • “Balance Billing”;
  • “To Litigate or Not to Litigate”
  • Potential “pitfalls” and useful practical suggestions.
Webinar Agenda
  • Understanding the concepts
  • Is it really a clinical denial ?
  • Is the denial notice or adverse benefit determination legally and factually sufficient?
  • Is the health plan fully insured or self-funded and why this is critical?  
  • Getting what you need to know what to appeal
  • Can you even appeal in the first place?
  • What appeal process applies?
  • The substance of the appeal
  • ERISA plan administrators altering plan benefits 
  • Litigation
  • Denials and “Balance Billing” in the age of patient protection legislation
Webinar Highlights
  • Making sure at the time that services are rendered that you will have the authority to appeal any denial of the claim 
  • Rules and regulations to cite to the plan when demanding a proper denial notice
  • The importance of distinguishing between federally regulated and state regulated health plans and insurers
  • Litigation practice hints
  • Whether you legally may “balance bill” the patient and the limitations of new state and federal legislation protecting patients from “surprise” and emergency bills.
Who Should Attend
  • Hospital and Medical Group Case Managers
  • Clinical Review Professionals
  • the Billing Office Managers and Appeals/Reconsideration Staff of any Clinical Provider
  • Employed and Retained Legal Counsel to Hospitals and Medical Groups
Thomas J. Force, Esq.

Thomas J. Force, Esq.

As a state and federally licensed attorney in both New Jersey and New York, Mr. Force has over 30 years of experience in the healthcare and insurance industries. His success as a Wall Street insurance litigator and his tenure as General Counsel for a New York-based Accident and Health Insurance Company where he served as Chief Compliance Officer propelled the founding of The Patriot Group. The Patriot Group is a full service revenue recovery company that provides billing, collections, and follow-up services as well as assistance with managed care appeals, managed care contracting, credentialing and compliance. Mr. Force is nationally recognized as an expert in revenue collection...
Read More