Clinical Legal Partnerships to Overturn More Denials

In response to payers overturning fewer and fewer denials in the face of appeals clearly proving the medical necessity of care provided to patients, providers should consider a Clinical-Legal Dispute Resolution approach.
A multi-disciplinary team at AppealMasters is finding new-found success using a variety of innovative methods to compel insurers to re-open and pay previously closed and upheld claims. Learn strategies such as involving state Departments of Insurance, CMS, and the Department of Labor for ERISA governed claims.
As insurers too often enjoy an unlevel playing field when it comes to denying care, appeal experts Brian McGraw and Kendall Smith share what is working for their clients. Revenue Cycle, Managed Care and Clinical Appeal Specialists will learn new appeal strategies to increase overturns and protect their hard-earned revenue.
Learning Outcomes:
Identify the first step in implementing state Insurance Department actions for egregious denials that are unfounded and not clinically supported.
Identify one federal provider protection that can be utilized in technical, medical necessity and clinical validation appeals.
Identify two avenues beyond the Payer Appeal procedures to escalate the decision outside of the Payer’s court of opinion.
Identify the state agency that regulates the state medical insurance laws that can be utilized to buttress clinical appeals.

Presenter: Brian McGraw; President of Intersect Healthcare
Brian is the President & CEO of Intersect Healthcare and the Denial Research Group (AppealMasters), each firm a national leader in their respective categories for Appeal Support services and next-generation Denial/Appeal Management. The denial technology and revenue recovery methods he designed are currently used by over 300 hospitals and health systems nationwide. As a fierce advocate for hospitals and physicians in their right to be fully paid, he consults with and educates revenue cycle and compliance leaders throughout the U.S. on government and commercial claim dispute resolution management.
He is a nationally recognized speaker and sought-after expert in the areas of Revenue Risk Management, Regulatory Audit Management and Payer Compliance.  Brian pioneered the early design and development of BPM software for revenue compliance and next-generation RCM technology to improve hospital net revenue performance. Over the last twenty years, he has worked with hundreds of hospitals and many of the nation’s largest healthcare systems to improve their managed care reimbursements, denied claim recoveries, billing integrity, RAC audit management and Medicare compliance.

Presenter: Kendall Smith, MD; Chief Physician Advisor
Dr. Kendall Smith is a Senior Fellow in Hospital Medicine (SFHM) and currently acts as Chief Physician Advisor for AppealMasters, a leading appeal educator and appeal services firm for hospitals and health systems. He’s been deeply involved in denial and appeals management throughout his hospitalist career, working collaboratively with UR/Case Management departments as well as Managed Care and Hospital C-Suite executives.
His familiarity with managed care denials led him to design and implement a number of CDI programs, including those at the Cleveland Clinic in Florida and the MedStar Washington Hospital Center. He has served as a physician leader on hospital revenue cycle management teams while also serving as a the Physician Advisor for Clinical Resource Management. Dr. Smith is also an AHIMA ICD-CM/PCS approved trainer/ambassador.