Learning Objectives:

• To review what is in and out of network billing.
• To review In and out-of-network requirements.
• To review federal plan requirements for out-of-network providers.
• To review the life of the claim.
• To review what the appeal process means.
• To review the appeal process for in and out-of-network providers.
• To understand the timing of when an appeal is appropriate.
• To understand what attachments are needed for appeal.
• To discuss ways how to set protocols for successful follow-up of denied claims for in and out-of-network providers.

Areas Covered in the Session

• In and out of network billing rules and requirements
• The appeal process for in and out-of-network providers
• When and how to Appeal
• Documents required for the appeal
• Setting protocols for successful follow-up of denied claims for in and out-of-network providers
• What is In-Network Billing
• What is Out-of-Network Billing
• In and Out-of-Network Requirements
• Commercial Payer Out-of-Network Policies and Products
• Federal Plans Requirements for Out-of-Network
• Medicare Advantage & Medicaid MCO
• Dos and don’ts about being Out-of-Network
• Examples of In-Network Reimbursement
• Examples of Out-of-Network Reimbursement
• Possible benefits of going Out-of-Network
• Examples and general guidelines to state regulations for Out-of-Network and balance billing
• No Surprises Act
• No Surprises Act: good faith estimate
• Life of the claim: Revenue Cycle Management
• Denials and how do we deal with them?
• Appeal process
• Appeal rights for in and out-of-network providers
• How to appeal?
• Appeal example: Medicare
• Appeal example: Medicare 2nd level
• Medicare Appeal: Process Summary
• Appeal example: AETNA
• Appeal example: BCBS (Blue Cross Blue Shield Association) of MD
• Appeal example: CIGNA
• Appeal example: UHC (United HealthCare)
• Appeal attachments
• Ways How to be Proactive
• How to have better control of your practice?

Suggested Attendees

• Medical providers, who are involved in the payment process of their practice
• Physicians
• Practice Managers
• Billing Managers
• C-level executives
• Office managers
• Medical billers
• Medical Coders
• Office staff and Billing Managers
• Medical Billing Companies
• Providers’ Office Staff
• Hospital Revenue Cycle Staff

About the Presenter