Denial and Appeal Management Webinars

These 60-to 90-minute free webinars provide in-depth study on successful denial and appeal management methods for specific issues or payers.

Webinars on this page have been previously recorded and may contain links or features that are no longer applicable or available to viewers.

Identifying Clinical Validation Denials and Creating Successful Appeal Strategies

Presented by AHDAM.org | 10/07/2020

Summary: Clinical validation denials can be challenging as payers do not always provide accurate, applicable, or sufficient denial rationale. Learn to identify clinical validation denials and how to appeal some common denial rationale.

Learning Outcomes:

• Explain 3 ways to determine if a denial is an inpatient clinical validation denial
• Describe 3 winning strategies for appealing clinical validation denials

Presenter: Karla Hiravi, RN, BSN; Clinical Audit and Appeal Services, Denial Research Group – 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/Integrity (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. Karla has been with the Denial Research Group – AppealMasters since 2016 and continues to participate in and educate about the medical appeal process.

Identifying Payer Denials and Creating Successful Coding Appeal Strategies

Presented by AHDAM.org| 08/26/2020

• Distinguish clinical validation and medical necessity denials from coding denials.
• Identify trends in payer denials.
• Apply successful coding appeal strategies when the denial rationale is unclear.

Presenter: Malissa Powers, B.S., RHIT, CCS, CDIP CICA | Appeal Consultant
Intersect Healthcare + AppealMasters

The Legal and Regulatory Aspects of Appeals in Denial and Appeal Management

Presented by AHDAM.org| 07/22/2020

A successful appeal may require the use of clinical, legal/regulatory, or contract language in the argument. Most appeals require all three. Many appeal writers are well versed in clinical or coding arguments, but the legal/regulatory arguments required for a successful appeal are just as important. David Glaser, Esq., attorney at Fredrikson & Byron, P.A., and Denise Wilson, senior vice president at Denial Research Group/AppealMasters and AHDAM president cover the legal and regulatory aspects associated with successful appeals. In this 60-minute webinar, David and Denise will teach you best practices for interacting with auditors, discerning regulatory rules, structuring complete appeal arguments, and preparing for hearing.

Learning Objectives:

  • Explain the critical steps involved in the first contact with an audit/auditor;
  • Discern what rules apply to Traditional Medicare versus Commercial payers;
  • Prepare and submit a well-structured appeal argument complete with appropriate clinical, legal/regulatory, or contract language;
  • Describe best practices for preparing for hearing.

Appealability: Assessing and Rating a Denial
for the Possibility of Overturn

Presented by Denial Research Group | 09/11/2019

Many hospitals are finding they don’t have adequate resources to keep up with the demands of appealing denials. Sometimes it doesn’t make sense to go after all denied claims. The better approach may be to employ your current resources to appeal denials with the best chance for overturn. Join us as we teach you how to develop your own payer-specific scoring system! Viewers will learn how to analyze types of denials to increase chances of revenue recovery.

Learning Objectives:

  • List the elements required in medical record documentation for a successful appeal
  • Select and assign a scoring system that is specific to the denial issue
  • Assess the accuracy of the scoring system

Successfully Appealing Denials With the Use of
Evidence Based Medicine and Standards of Care

Presented by Denial Research Group | 06/05/2019

When arguing the medical necessity of the level of care or procedure or services provided, the argument always comes down to whether or not care was provided according to acceptable standards of care in the medical community.

But, how do you know what the acceptable standards of care are? Where do you find them? How do you incorporate the argument into your appeal? Where do screening tools come into play? Join us as we share strategies for incorporating standard of care arguments in your appeals.

Learning Objectives:

  • Define standards of care in the medical community
  • Demonstrate sources for successful research of standards of care
  • Describe how to incorporate standards of care in a successful appeal

Successfully Appealing Clinical
Validation Issues in Sepsis-3

Presented by Denial Research Group | 01/23/2019

Appeal writers want to know how to defend sepsis denials in the era of Sepsis-3. What’s the future for clinical validation denials and appeals when major payers declare their use of Sepsis-3 in their reviews? How can hospitals reconcile their sepsis criteria versus the payers’ criteria?

Here we present an update on what Denial Research Group/AppealMasters has learned over the years from appealing hundreds of clinical validation denials for sepsis. Hear what our experts have to say about the disconnect between payer criteria and hospital criteria. We reveal payer behaviors regarding auditing and denying sepsis codes. And, as always, we share proven, successful appeal strategies that you can use right away.

Learning Objectives:

  • Describe recent trends in auditing, denials, and appeals of sepsis cases
  • List common payer denial rationale
  • Describe successful strategies to compose winning appeals when sepsis is denied, even though you got it right.

Successfully Appealing
Readmission Denials

Presented by Denial Research Group | 07/31/2019

Hospital readmissions for related conditions remains a huge target for audits and denials. Join us as we share what Denial Research Group/AppealMasters has learned over the years from appealing hundreds of readmission denials on behalf of hospital clients.

Learning Objectives:

  • Define standards of care in the medical community
  • Demonstrate sources for successful research of standards of care
  • Describe how to incorporate standards of care in a successful appeal

Successfully Appealing Clinical Validation and
Coding Issues in Acute Blood Loss Anemia

Presented by Denial Research Group | 11/07/2018

Acute blood loss anemia remains a target for both clinical and coding validation. Why is that? We  discuss current coding guidelines and clinical indicators for acute blood loss anemia. We discuss why coding and clinical denials for acute blood loss anemia are different and why different appeal strategies are necessary. And, as a special “twofer”, we also present a summary of clinical validation considerations and appeal strategies for a variety of diagnoses that are the target of payer audits.

Join us as we share what Denial Research Group/AppealMasters has learned over the years from appealing hundreds of coding and clinical validation denials for acute blood loss anemia and other popular diagnoses that were denied on a clinical basis. We reveal payer behaviors regarding auditing and denying these diagnosis codes. And, as always, we share proven, successful appeal strategies that you can use right away.

Learning Objectives:

  • Understand common denial rationale
  • Recognize the differences between coding and clinical denials
  • Discover successful strategies to compose winning appeals when acute blood loss anemia and other common diagnoses are denied, even though you got it right

Successfully Appealing Medicare
Advantage Denials

Presented by Denial Research Group | 04/24/2019

Join us as we share strategies for overcoming the biggest obstacles to successful MAO appeals. We share what Denial Research Group/AppealMasters has learned over the years from appealing hundreds of denials from Medicare Advantage Plans on behalf of hospitals. We reveal payer behaviors regarding auditing and denying services and all the rules around MAO plans.

Learning Objectives:

  • Describe how MAO plans differ from traditional Medicare
  • Explain the difference between Par and Non-Par payer relationships
  • List the steps in the MAO appeals process
  • Outline the process to appeal on behalf of the beneficiary

Developing a Meaningful Denial and Appeal Dashboard

Presented by Denial Research Group | 02/12/2019

Meaningful dashboards are essential to successful denial and appeal management.  A dashboard provides insight into payer trends as well as appeal success and failures. Building a meaningful dashboard involves identifying relevant data and classifying it in a way that brings information to light. Join us as we share methods for developing meaningful dashboards that can build success into denial and appeal management

Learning Objectives:

  • List data relevant to denial and appeal management
  • Classify data in a meaningful way that brings information to light
  • Build and implement dashboards that bring success to denial and appeal management

Successfully Appealing the Decision to Admit To Inpatient

Presented by Denial Research Group | 12/04/2019

Physician advisors and appeal writers working together to determine and defend appropriate patient status is a trend we applaud. However, sometimes the two teams are not working from the same playbook. In this webinar we’ll discuss the consequences of teams who are out of sync. We’ll share strategies you can employ to ensure physician advisors and appeal writers are working in tandem to determine and defend appropriate patient status.

Learning Objectives:

  • List level of care determinations by payer
  • Cite supporting documentation for inpatient admission decisions
  • Close the feedback loop on appeal outcomes

Successfully Appealing Clinical Validation Denials

Presented by Denial Research Group | 10/23/2019

Clinical validation denials are still the hottest topic out there in the denial and appeal management world. AppealMasters began successfully appealing clinical validation denials almost a decade ago when Medicare’s Recovery Audit Contractors were the most voracious auditors out there.

Over the past several years the Commercial payers have ramped up their clinical validation audit efforts to levels never before seen. Successfully appealing these denials comes down to understanding the core issues behind the denials and implementing a few key appeal strategies. You can be successful in your appeals as well.

Learning Objectives:

  • List common clinical validation denial rationale.
  • Recognize the core issues in clinical validation denials.
  • Describe successful strategies to compose winning appeals when the payer denies the diagnosis, even though you got it right.

Successfully Appealing Clinical Validation and Coding Issues in Malnutrition and Congestive Heart Failure

Presented by Denial Research Group | 09/19/2018

Malnutrition remains a target for both clinical and coding validation. Why is that? We will discuss current coding guidelines and clinical indicators for malnutrition. We will discuss why coding and clinical denials for malnutrition are different and why different appeal strategies are necessary. And, as a special “twofer”, we’ll also present coding and clinical validation considerations and appeal strategies for congestive heart failure denials.

Join us as we share what we’ve learned over the years from appealing hundreds of coding and clinical validation denials for malnutrition and congestive heart failure on behalf of our hospital clients. We’ll reveal payer behaviors regarding auditing and denying these diagnosis codes. And, as always, we will share proven, successful appeal strategies that you can use right away.

Learning Objectives:

  • Understand common denial rationale.
  • Recognize the differences between coding and clinical denials for malnutrition and congestive heart failure.
  • Discover successful strategies to compose winning appeals when the malnutrition and congestive heart failure diagnosis is denied, even though you got it right.

Successfully Appealing Clinical Validation and Coding Issues in AKI, ATN and Pneumonia

Presented by Denial Research Group | 08/8/2019

Acute Kidney Injury (AKI) and Acute Tubular Necrosis (ATN) remain a target for both clinical and coding validation. Why is that? We will discuss current coding guidelines and clinical indicators for AKI/ATN. We will discuss why coding and clinical denials for AKI/ATN are different and why different appeal strategies are necessary. And, as a special “twofer”, we’ll also present coding and clinical validation considerations and appeal strategies for pneumonia denials.

Join us as we share what we’ve learned over the years from appealing hundreds of coding and clinical validation denials for AKI/ATN and pneumonia on behalf of our hospital clients. We’ll reveal payer behaviors regarding auditing and denying these diagnosis codes. And, as always, we will share proven, successful appeal strategies that you can use right away.

Learning Objectives:

  • Understand common denial rationale.
  • Recognize the differences between coding and clinical denials for AKI/ATN and pneumonia.
  • Discover successful strategies to compose winning appeals when the AKI/ATN or pneumonia diagnosis is denied, even though you got it right.

Successfully Appealing Clinical Validation and Coding Issues in Encephalopathy

Presented by Denial Research Group | 01/24/18

Encephalopathy remains a huge target for both clinical and coding validation. Some denials are strictly coding, some are strictly clinical, and some are a combination of both, which are harder to appeal adequately as the writer needs knowledge of both worlds. We will discuss why coding and clinical denials for encephalopathy are different and why different appeal strategies are necessary.

Join us as we share what we’ve learned over the years from appealing hundreds of coding and clinical validation denials for encephalopathy on behalf of our hospital clients. We’ll reveal payer behaviors regarding auditing and denying this diagnosis code. And, as always, we will share proven, successful appeal strategies that you can use right away.

Learning Objectives:

  • Understand common denial rationale
  • Recognize the differences between coding and clinical denials for encephalopathy
  • Discover successful strategies to compose winning appeals when the encephalopathy diagnosis is denied, even though you got it right

Successfully Appealing Clinical Validation and Coding in Acute Respiratory Failure

Presented by Denial Research Group | 03/27/2018

Acute respiratory failure remains a huge target for coding and clinical validation audits and denials. We will discuss common reasons for denial of acute respiratory failure and how to respond using clinical criteria, coding criteria, or both.

Successfully Appealing Clinical Validation Denials for Sepsis

Presented by Denial Research Group | 12/20/2017

It’s been almost two years since The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) was published. How has the new definition impacted payer behavior regarding audits, denials, and appeals?

Join us as we share what we’ve learned over the years from appealing hundreds of clinical validation denials for sepsis on behalf of our hospital clients. We will discuss SIRS with infection versus Sepsis – 3 criteria and whether the different definitions even matter. We’ll reveal payer behaviors regarding auditing and denying this diagnosis code. And, as always, we will share proven, successful appeal strategies that you can use right away.

Learning Objectives:

  • Understand the difference between SIRS and Sepsis – 3 criteria
  • Understand payer behaviors regarding clinical validation audits for sepsis
  • Discover successful strategies to compose winning appeals when the sepsis diagnosis is denied, even though you got it right

Appealing Denials for Coding of BMI, Obesity and Morbid Obesity

Presented by Denial Research Group | 04/18/2017

You know the struggles associated with coding it correctly, only to have it denied by an auditor.

We will review what the provider needs to know, and also what your nurses and dietary staff need to know to get it right on the front end. Join us while we show you, using real life examples, how to successfully appeal a denial when your staff got it right.

Learning Objectives:

  1. Understand the coding rules concerning BMI, obesity, and morbid obesity
  2. Learn who to involve on the front end, and how to do it, to make your medical record as “bullet proof” as possible
  3. Discover successful strategies to compose winning appeals when the BMI and associated diagnosis are denied, even though you got it right

Winning Medicare Advantage Denials (Part 1 of 2)

Presented by Denial Research Group | 03/01/2017

If your hospital or health system serves a large Medicare Advantage population, you likely have significant Medicare Advantage denials and audits to deal with. Join our Medicare Advantage appeal experts in a practical review of Appeal Strategies, Appeal Writing and Appeal Escalation specifically related to Managed Medicare payment challenges. We’ll have specific appeal language, appeal rights and sample appealsfor Medicare Advantage denials including Diagnosis Validation/DRG Reassignment, Medical Necessity and Level of Care denials.

This second part of the webinar series covers real appeal writing tips and enforcement strategies, Wilson and Smith will be joined by a panel of clinical and legal appeal experts with first-hand successes and stories of what works and what doesn’t. We’ll address Medical Necessity as well as Diagnosis Validation/DRG Reassignment denials, and what you can immediately do to begin to turn the tide.

Winning Medicare Advantage Denials (Part 2 of 2)

Presented by Denial Research Group | 03/01/2017

If your hospital or health system serves a large Medicare Advantage population, you likely have significant Medicare Advantage denials and audits to deal with. Join our Medicare Advantage appeal experts in a practical review of Appeal Strategies, Appeal Writing and Appeal Escalation specifically related to Managed Medicare payment challenges. We’ll have specific appeal language, appeal rights and sample appealsfor Medicare Advantage denials including Diagnosis Validation/DRG Reassignment, Medical Necessity and Level of Care denials.

This second part of the webinar series covers real appeal writing tips and enforcement strategies, Wilson and Smith will be joined by a panel of clinical and legal appeal experts with first-hand successes and stories of what works and what doesn’t. We’ll address Medical Necessity as well as Diagnosis Validation/DRG Reassignment denials, and what you can immediately do to begin to turn the tide.