Successfully Appealing High Dollar Denials Involving NCDs and LCDs

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.

About the presenters:

Karla Hiravi, RN, BSN

Vice President | PayerWatch – AppealMasters

Karla is a registered nurse and holds a BSN from the University of Pittsburgh, Johnstown. She has over thirty years of varied experiences in healthcare, including Clinical Documentation Improvement (CDI), 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.

She has extensive experience developing material for continuing education. She was a frequent guest speaker at the University of Pittsburgh, Johnstown for many years, and served as a preceptor for nurse practitioner and Pharm D. students while they studied medical research through the University of Pittsburgh. Karla has been with the Denial Research Group – AppealMasters since 2016 and continues to participate in and educate clinicians and coders about the medical appeal process.

Denise Wilson MS, RN, RRT

President | Association for Healthcare Denial and Appeal Management

Senior Vice President | PayerWatch – AppealMasters

Denise serves as the Senior Vice President at PayerWatch – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise is a Registered Respiratory Therapist, Registered Nurse, and holds a master’s degree in management information systems from the University of Illinois, Springfield. Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.

Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials. Denise’s special area of expertise is in writing and producing successful appeals.