Successfully Master Level of Care Denials in a Managed Care World

Managed Care Organization denials for inpatient level of care are some of the most difficult denials to prevent and overturn on appeal. Payer-specific rules, contracts, and definitions of inpatient care can overly complicate the process of avoiding denials and successfully appealing level of care decisions. Join us as we present successful strategies for mastering level of care denials in a managed care world.

Learning Outcomes:

  • Name the 2 primary locations where managed care payers publish their definition of inpatient status
  • Explain 2 differences between internal and external appeal processes
  • List 3 responsibilities of the clinical or coding appeals team in responding to managed care level of care denials to optimize denial avoidance and appeal success.

Presenter: Denise Wilson, MS, RN, RRT; Senior Vice President, Denial Research Group – AppealMasters, President, AHDAM

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 healthcare denials.