Denial and Appeal Writing Webinars

Upcoming Webinar:

Tackling Readmission Denials Webinar
         Wednesday, July 24, 2024 | 2:00 p.m. ET

Medicare’s Hospital Readmissions Reduction Program (HRRP) has expanded into the commercial and managed care arenas. Join us as we discuss the various readmission reduction programs and successful strategies for overturning the resulting denials.

Learning Outcomes:  At the conclusion of the webinar, the learner will be able to self report they can:
1. Identify at least three of the conditions included in the Hospital Readmission Reduction Program from the Centers for Medicare and Medicaid Services.
2. Identify one circumstance when a readmission may have been appropriate.
3. Identify one method of defending appropriate readmissions through the appeals process.

About the presenters:

Reginald Allen, MBA, RN, ACM, Chief of Clinical/Business Operations, PayerWatch
Reggie has more than 35 years of experience in a variety of healthcare positions, including staff nurse, nurse manager, Chief Nursing Officer, Chief Operating Officer, and Vice President, Clinical/Business Operations Transformation.  He has been recognized nationally as an expert in care management and clinical operations.   He is a results-driven leader who emphasizes operational transformation by integrating clinical and financial care aspects.  He obtained a bachelor's degree in nursing from Vanderbilt University and an MBA from the University of Phoenix.   He is a member of the American Case Management Association (ACMA) and the American College of Healthcare Executives.  

Reggie possesses comprehensive knowledge and experience in all facets of care management, including case management, utilization management, disease management, quality management, and resource management.  He has designed and implemented an enterprise-wide Clinical Appeals Unit and a clinical documentation program with success.  Using six sigma and Lean principles, he is an expert in clinical and operational efficiencies that enhance clinical outcomes and financial performance through a variety of methodologies. 

Karla Hiravi, BSN, RN, AHDAM President Senior Vice President, PayerWatch 
Karla is a registered nurse and holds a BSN from the University of Pittsburgh, Johnstown. She has over forty years of varied experiences in healthcare, including Clinical Documentation Improvement (CDI), management of a CDI department, development of a hospital-based denial and appeal program, development of an oncology research program, nurse and physician education, appeal writing, presentations at the Administrative Law Judge (ALJ) level, and direct management of appeals at every level, up to post ALJ appeals.

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You must register with a business or provider email domain. General email accounts such as Gmail or Yahoo will not be approved for attendance. CE/CME's for AHDAM Members Only. 


Browse the archive of past webinars below.


AHDAM WEBINAR ARCHIVE:

These 60-to 90-minute free webinars provide in-depth study on successful denial and appeal management methods for specific issues or payers.  Please note that webinars archived below may contain links or features that are no longer applicable or available to viewers.

 


 The Emerging Role of Artificial Intelligence (AI) in Healthcare Denials and Appeals

Presentation Date: Wednesday, March 27, 2024

The emergence of artificial intelligence (AI) has undoubtedly already impacted healthcare denials and appeals processes. Join us as we provide a comprehensive overview of AI’s emerging role in healthcare denials and appeals processes by focusing on the benefits, regulatory limitations, and ethical considerations. This webinar is tailored for healthcare professionals managing insurance denials for care provided by hospitals.

Presenters: 

  • Kendall Smith, MD, Chief Medical Officer/ Chief Physician Advisor, PayerWatch
  • Vivek Radhakrishna, Chief Technology Officer, PayerWatch

Download the Slide Deck

 

Clinical Validation Appeals - Back to the Basics Part 2:  Questions and Answers

Presentation Date: Wednesday, February 21, 2024

We asked for questions, and you sent them! Join us as we answer questions from Part 1 of Clinical Validation Appeals – Back to the Basics. Because clinical validation denials continue to rise, it is imperative that denial and appeal management professionals understand the differences between coding and clinical validation denials and how to successfully appeal clinical validation denials. 

Presenters: 

  • Christi Drum, RN, BSN, CCDS, CCS, Senior Director of Clinical Appeals for Clinical Validation and Coding, PayerWatch/AppealMasters 
  • Karla Hiravi, RN, BSN, President, AHDAM and Vice President, Clinical Resources, PayerWatch/Appeal/Masters

 


 

Medicare Advantage and the 2-Midnight Rule in 2024

Presentation Date: Wednesday, November 29, 2023

The date for the CMS Final Rule (CMS-4201-F) on Medicare Advantage Plans (MAP) is approaching fast. The final rule published 4/15/2023 goes into effect on 1/1/2024. Are you ready? This is the rule that reinforces the expectation from CMS that MAPs follow the 2-midnight rule that has been in place for traditional, Fee-for-Service (FFS) Medicare for 10 years. The Final Rule also reinforces the expectation for MAPs to adhere to the inpatient-only procedures list. What is your team doing to prepare?

Join us as we discuss the specifics of the Final Rule that apply to MAPs, the 2-midnight rule, the inpatient-only list, and denials and appeals. We’ll discuss what you need to do now to ensure your team is ready for the new rule. Special attention will be given to how to monitor and report MAP compliance with the new rule. We can’t level the playing field if we aren’t all following the same rules.

Presenters:
  • Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch + AppealMasters, President, AHDAM
  • Kendall Smith, MD, Chief Physician Advisor, PayerWatch + AppealMasters

Download the Slide Deck
Government Patient Status Appeal Template

Successfully Defending Outpatient Authorization Denials

Presentation Date: Wednesday, October 18, 2023 

Obtaining preauthorization for outpatient services is vitally important in avoiding denials. But, even when preauthorization is obtained, denials can still occur. Denial and appeal management professionals must become experts in navigating the sea of outpatient preauthorization processes, denials, and appeals. Join us as experts in the field discuss ways to prevent authorization denials, how to hold payers accountable for delayed decisions, and strategies to defend outpatient authorization denials. 

Presenters:
  • Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch + AppealMasters, President, AHDAM
  • Reggie Allen, MBA, RN, ACM, Chief, Clinical/Business Operations | PayerWatch + AppealMasters

Download the Slide Deck

Clinical Validation Appeals - Back to the Basics

Presentation Date: September 20, 2023

Clinical validation denials continue to rise. It is imperative that denial and appeal management professionals understand the differences between coding and clinical validation denials and how to successfully appeal clinical validation denials. If you are new to clinical validation denials and appeals, or need a refresher on the basics, join us as experts in the field discuss how to identify coding versus clinical validation denials and learn proven strategies to successfully appeal clinical validation denials.

Presenters:

  • Christi Drum, RN, BSN, CCDS, CCS, Senior Director of Clinical Appeals for Clinical Validation and Coding| PayerWatch + AppealMasters
  • Karla Hiravi, RN, BSN, Vice President, Clinical Resources | PayerWatch + AppealMasters 

Download the Slide Deck
Q&A

Successfully Defending Inpatient Authorization Denials

Presentation Date: July 19, 2023

Authorizations for inpatient admissions remain a thorn in the sides of providers and utilization management personnel. Join us as experts in the field discuss ways to prevent authorization denials, how to hold payers accountable for delayed decisions, and strategies to defend inpatient authorization denials.

Presenters:

  • Denise Wilson, MS, RN, RRT, Senior Vice President | PayerWatch + AppealMasters, President, AHDAM
  • Reggie Allen, MBA, RN, ACM, Chief, Clinical/Business Operations | PayerWatch + AppealMasters 

Download the Slide Deck
Q&A

Experts Discuss the Key Points and Impact of the 2024 Medicare Advantage Final Rule (CMS-4201-F)

Presentation Date: June 21, 2023

On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises the Medicare Advantage (MA or Part C) regulations to implement changes related to health equity, coverage criteria, prior authorization, and other programmatic areas. Join us as experts in the field discuss the key points of the final rule that clarifies Medicare Advantage payer behaviors. We’ll also be discussing the impact the final rule will have on providers. 

Presenters:

  • Carolyn Dutton, MD, FACEP, FACP, Senior Physician Advisor, Wound Care Director, Emergency Medicine, Internal Medicine; Atrium Health 
  • Kendall Smith, MD, Chief Physician Advisor, PayerWatch + AppealMasters
  • Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch + AppealMasters, President, AHDAM 
Download the Slide Deck

Successfully Appealing High Dollar Denials Involving NCDs and LCDs

Presentation Date: May 3, 2023

Payment for many high-dollar procedures is governed by National or Local Coverage Determinations for traditional Medicare and Managed Medicare beneficiaries. Understanding the requirements of the NCDs and LCDs is instrumental to successful denial prevention and appeal success. Join us as we discuss identifying coverage requirements for common high-dollar procedures and how to employ the information in preventing denials and successfully appealing denials.

Presenters:

  • Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch + AppealMasters, President, AHDAM
  • Karla Hiravi, RN, BSN, Vice President, PayerWatch + AppealMasters
Download the Slide Deck

Appealing Chemotherapy and Biologicals Denials

Presentation Date: 3/29/2023

Successfully overturning chemotherapy and biologicals denials goes beyond writing a great medical necessity appeal.  Appeal specialists must understand medical necessity requirements, but also need to understand documentation requirements, billing of these drugs, where to find the information they need, and how to apply that information in an appeal. Join us as we discuss successful strategies for overturning these often high dollar denials.

Presenter: Karla Hiravi, RN, BSN, Vice President | PayerWatch - AppealMasters



Different Payers Means Different Appeal Strategies

Presentation Date: 3/1/2023

So often the answer to ‘How do I appeal this or that?” depends on the answer to “Who is the payer and do you have a contract?” Join us as we discuss the variability in the appeals process based on payers and payer contracts.

Presented By: Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch/AppealMasters, President, AHDAM


Anatomy of Successful Medical Necessity Appeals

Presentation Date: 1/25/2023

Everyone wants to know the most effective structure of a written medical necessity necessity appeal argument. Join us as we discuss efficient and effective methods for structuring the written appeal for medical necessity inpatient and outpatient services.

Presented By: Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch/AppealMasters, President, AHDAM

Download Slides
Download Sample Knee
Download Sample IP

Dispelling Widespread Misunderstandings of the CMS Two-Midnight Rule

Presentation Date: 12/15/2022

Special guest speaker, David Glaser, shareholder at Fredikson & Byron, PA, clarifies widespread misunderstanding of CMS Two-Midnight Rule. David will be covering tips for ensuring the UM team is focused purely on physician expectation, not InterQual or MCG. He will be sharing how outdated Manual provisions may cause people to wrongly conclude inpatient status is improper. His guidance will help those involved in denial and appeal management recognize why auditors are wrong when they deny an admission asserting that the patient “only required an outpatient level of care.” And, he will present the compelling legal argument that Medicare Advantage cannot ignore the 2 midnight rule.

Presented By:

  • David Glaser, Shareholder, Fredikson & Byron, PA
  • Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch/AppealMasters, President, AHDAM

Download Handout

Total Joint Surgery Denials and Appeals

Presentation Date: 11/9/2022

Receiving appropriate reimbursement for total joint surgeries requires solid processes and education of providers and revenue cycle staff. Join AHDAM Advisory Board member DeAnna Fling and AHDAM President Denise Wilson in discussing best practices to prevent denials and win appeals for total joint surgeries.

Presented By:

  • Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch/AppealMasters, President, AHDAM
  • DeAnna Fling, RRT, MHA, Revenue Cycle Educator and Operations Support
    US Oncology Network-McKesson Pharmaceutical Solutions and
    Services

Best Practices in the Appeals Process Provider

Presentation Date: 9/21/2022

Successfully overturning denials goes beyond writing a great appeal. Appeal specialists must employ best practices at every level of both the internal and external appeals process starting with peer-to-peer. Many AHDAM members are asking how best to manage various levels of appeal from a process as well as an appeal argument standpoint. In this session we will present best practices for government and commercial payers’ appeal processes.

Presented By:

  • Kendall Smith, MD, Chief Physician Advisor, PayerWatch/AppealMasters 
  • Denise Wilson, MS, RN, RRT, Senior Vice President, PayerWatch/AppealMasters, President, AHDAM
Download Handout

Medicare Advantage Denials: A Call to Arms

Presentation Date: 8/23/2022

Recently CMS requested that all interested healthcare providers make comments on the Part C Medicare Advantage program by Wednesday, August 31st.  A 2022 report from the OIG shows just how much our patients are suffering as a result of the “big business” that are Medicare Advantage plans.  By literally privatizing Medicare, CMS has let the proverbial foxes into the henhouse, and they have no incentive to leave. This needs to change.

Join Medicare Advantage denial and appeal experts Dr. Brian Moore and Brian McGraw as they discuss the top 5-10 major issues that should be brought to the immediate attention of CMS program administrators and congressional leaders. Denise Wilson will moderate the discussion and provide additional step-by-step instruction on how to easily make your voices heard from every corner of the country.

Presented By:

  • Brian McGraw, President & CEO of PayerWatch and the Denial Research Group (AppealMasters)
  • Dr. Brian Moore, FACEP CHCQM-PHYADV, Chief Medical Officer – Physician Advisor Services at Atrium Health

Legal Arguments for Clinical Appeals

Presentation Date: 7/20/2022

Writing a great clinical argument for medically necessary services is no longer enough to win appeals. Appeal specialists must employ all entitled rights of appeal and that includes understanding and incorporating legal arguments. In this session we will present legal arguments that any clinician can understand and that apply to the most common situations encountered in denials, such as Emergency Services and EMTALA, authorization, experimental or investigational, and others.

At the conclusion of the webinar, the learner will be able to Insert basic legal arguments into an appeal letter, incorporating the correct legal argument for the specific situation. The learner will be able to:

  • Describe the purpose of including legal arguments in clinical appeals
  • Identify the agency in their state that sets legal regulations for medical insurance
  • Match up one legal argument with the appropriate circumstances for use

Presented By: Denise Wilson, MS, RN, RRT


 Fighting Readmission Denials

Presentation Date: 6/22/2022

Medicare’s Hospital Readmissions Reduction Program (HRRP) is approaching its 10th birthday. That has provided commercial and managed care plans plenty of time to follow suit and create their own version of a readmission review program with associated penalties. Join us as we discuss the various readmission reduction programs and successful strategies for overturning the resulting denials.

At the conclusion of the webinar, the learner will be able to write a persuasive argument focused on defending the medical necessity of the patient’s readmission. The learner will be able to:

  • Identify at least three of the conditions included in the Hospital Readmission Reduction Program from the Centers for Medicare and Medicaid Services
  • Identify one circumstance when a readmission may have been appropriate
  • Identify one method of defending appropriate readmissions through the appeals process

Presented By: Denise Wilson, MS, RN, RRT


Seal Training - The Simple Effective Appeal Letter

Presentation Date: 5/18/2022

AHDAM has received many requests for how to structure a successful appeal letter. Join us as we explore the simple, effective appeal letter format that brings efficiency and effectiveness to the management of denials and appeals.

At the conclusion of the webinar, the learner will be able to:

  • Identify the five areas of focus of medical record documentation for support of the inpatient admission
  • Identify the two sections of the history and physical that contain the most valuable information to include in the appeal for inpatient admission
  • Identify two objective patient assessments that support the patient’s need for inpatient admission

Presented By: Denise Wilson, MS, RN, RRT

SEAL Training - The Simple Effective Appeal Letter Q&A

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