Whether by the U.S. Congress or the Mississippi Legislature, there are many rules and regulations in place clearly defining the working relationship between Mississippi healthcare providers and health insurers. But one aspect of the relationship that is unregulated is the issue of what constitutes medically necessary care for purposes of health insurance reimbursement.
This presentation will cover the following:
- How Mississippi health insurers define “medically necessary” care
- Health insurer practices regarding authorization and medical necessity denials
- Tips for composing appeals to overturn clinical denials
- Laws, regulations, and common law principles that can be utilized when laying out the healthcare provider’s argument
The workshop is designed for personnel involved with appealing, overturning, and preventing clinical denials.
- To obtain a better understanding of Mississippi’s commercial health insurers’ practicesin denying payment for services based upon a clinical reason.
- To identify common areas for healthcare providers to address to prevent the clinical denials from occurring.
- To obtain pointers and suggestions for drafting persuasive appeals on the provider’s behalf to overturn the denials.
December 2, 2020
1.0 – Revenue Cycle Management
Laurie Beck, BSN, RN, CCM
Senior Vice-President, Clinical Operations
As the Senior Vice President of Clinical Operations, Laurie and her team of multi-specialty nurses research and write appeals for both Inpatient and Outpatient claims. She and her team have routinely successfully overturned denials for a variety of denial reasons including Level of Care, Length of Stay, Readmissions, Experimental/Investigational, and No Authorizations. In addition, Laurie has provided both hospital-specific and payer-specific trends related to root cause issues of denials and underpayments.
Laurie has worked in Case Management/Utilization Review for over 15 years for both acute care hospitals and companies focused on healthcare revenue recovery. She has worked in a variety of healthcare settings including acute care and ER hospital settings, Inpatient Rehab, and Skilled Nursing Facilities. She also has worked as a Legal Nurse Consultant. Laurie has extensive knowledge of healthcare rules and regulations for commercial and government payers, as well as a thorough understanding of internal hospital processes that impact the revenue cycle processes.
Laurie received her Bachelor’s Degree in Nursing from Florida Southern College and obtained her State of Florida Nursing License.
Stacy Gearhard, JD, LLM, CHPC
Co-Founder and Principal
As Co-Founder and Principal, Stacy encourages every team member at Advicare to think outside the box and to seek creative and innovative ways to grow personally and professionally. She has worked exclusively with healthcare institutions across the US for the past 20+ years because she loves working on complex issues and projects that benefit patients and providers alike.
Stacy’s passion for leveling the playing field for patients and providers in their dealings with insurers inspired her to co-found her first company, Trilogi, Inc. – a national healthcare receivables management company that provided multiple revenue recovery services. As the Co-Founder of Advicare, Stacy narrowed her focus to clinical denials because she recognized that these are the most complex and problematic denials for providers to resolve – they also have the greatest impact on a hospital’s net revenue than any other denials. By forming collaborative teams of nurses, attorneys and coders, Stacy and her partners endeavor to bridge the gap between patient finance and clinicians to resolve and prevent clinical denials on behalf of our clients.
Stacy received her Juris Doctor from Loyola University School of Law in New Orleans and her Master of Law in Health Law from Loyola University School of Law in Chicago. She is also an active member of the HFMA, AAHAM, and AHLA (American Health Lawyers Association) and certified in Healthcare Privacy Compliance by the Health Care Compliance Association.