Appealing Denials for the Medical Necessity of a Procedure


Wednesday, April 8, 2015

Please log in on the right side of the page, or Register as a new member.

Join appeal expert Denise Wilson, RN, MS, RRT, as she shares best practices for wining appeals, especially when the care provided doesn’t strictly follow payment policies.

Listen & Watch the Webinar

What you will learn

  • Where to find LCDs, NCDs, and CPGs
  • The language and purpose of LCDs, NCDs, and CPGs
  • How to craft a winning argument when care doesn’t strictly follow payment policies

Commercial payers are quite adept at denying the medical necessity of surgeries and procedures. That’s nothing new. Now, while a major respite on level of care denials for government appeals has been in place for the past 18 months, the number of audits and denials for the medical necessity of procedures in that payer arena has been on the rise.

CMS publishes local coverage determinations (LCDs) and national coverage determinations (NCDs) while commercial payers publish clinical practice guidelines (CPGs) as a means of communicating payment policies. However, those guidelines aren’t always the final word. An appeal can still be successful even when the documentation in the medical record does not match exactly the strict guidelines of a payment policy. Join us for a complimentary webinar to learn how to write winning appeals when an LCD, NCD or CPG is involved.

About your presenter

Denise Wilson, RN, MS, RRT

Denise serves as Assistant Vice President, Training and Education for AppealMasters, the appeal service group of the Intersect Healthcare family. With over thirty years of experience in healthcare, including clinical management, education, compliance, audit, and denials, Denise has educated thousands of healthcare professionals across the country on the art and science of writing winning appeals. She has personally managed hundreds of appeals and presented dozens of cases at the Administrative Law Judge level with a 95% success rate.

Denise serves as the main line of training, communication and support for Intersect Healthcare clients and our dedicated team of clinical appeal specialists. Denise has extensive experience as a successful Medicare Appeal Expert and has peronally managed over 350 ALJ appeal cases with an astounding 95% success rate. Denise shares her knowledge and experience of appeal processes and the creation of successful appeals with IHI clients and any willing provider, absolutely free of charge. She is especially skilled in workflow design and performance improvement surrounding the claim dispute resolution process. Denise has more than twenty-five years experience in healthcare management, including four years as a Compliance Officer. She is a Registered Respiratory Therapist, Registered Nurse, and holds a Master of Science degree in Management Information Systems from the University of Illinois, Springfield.