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| Navigating the 10th Circle of Hell: A Road Map to Effectively Appealing Insurance Denials |
| Saturday, May 28, 2016 |
| 4:00 PM–7:00 PM |
| St. Gallen 3, Swissotel |
| Area: PRA/AUT; Domain: Service Delivery |
| CE Instructor: William Tim Courtney, M.S. |
| WILLIAM TIM COURTNEY (Little Star Center), BREANNE K. HARTLEY (Little Star Center ), VINCENT LAMARCA (Little Star Center), MARY ROSSWURM (Little Star Center) |
| Description: In this workshop, the presenters will discuss how to respond when an insurance company has partially, or completely denied hours. Unfavorable determinations of medical necessity and the subsequent appeals is a fairly common aspect of providing medical services. In 2011, the Center for Medicare and Medicaid services (CMS) paid out 37.9 million dollars as a result of medical appeals. The appeal process can be very timely and heavy on clinical resources. This presentation looks to reduce the time required to analyze adverse determination letters, formulate appeal arguments, and solicit the help from parents and other key players. Attendees will review a case that consisted of several levels of internal appeals, as well as the external appeal process. The workshop is laid out in a behavior skills training format, in which the presenters will model effective procedures, provide instructions, and then have attendees role play behavior with feedback provided by the presenters. Attendees will receive example appeal letters, worksheets for reviewing denial letters, and example spreadsheets utilized to track the appeal process. |
| Learning Objectives: At the conclusion of the workshop, the participant will be able to: (1) analyze denial letters to determine the primary reason for the denial; (2) describe the internal and external appeal process; (3) develop appeal letters, grounded in medical necessity, specifically addressing the reason for the denial; (4) develop strategies to involve family members and other advocates in the appeal process. |
| Activities: The workshop follows a behavior skills training format. The presenters will provide instructions and model strategies effective within their organization. Attendees will then practice strategies, while receiving feedback from the presenters. |
| Audience: The workshop is primarily targeting providers with experience providing medically necessary services, with a history of working through the appeal process. Attendeesthat are just starting to provide medically necessary services could benefit by being aware and practicing the presented appeal strategies. |
| Content Area: Practice |
| Instruction Level: Intermediate |
| Keyword(s): ABA Practice, Autism, Billing, Insurance Mandate |