Clinical Appeals Denials
Researched and wrote appeals for hospitals and outpatient facilities across the country, along with testifying as medical witness in over 100 Medicare and Medicaid hearings. I won more than 2/3 of all appeals in both categories. Was assigned only cases of five or six figures or in denied payment. Have experience in appealing denials made for nearly every reason, including all types of medical necessity, Medicare and Medicaid rules, regulations and policies, experimental/investigative, line-item, bundling, coding, downcoded DRGs, line-item denials, Milliman and InterQual, observation vs. inpatient, air transport, level of care, non-emergent, lack of documentation, and specific services provided in Inpatient Psychiatric and drug abuse cases and behavioral health, Skilled Nursing Facilities, Inpatient Rehabilitation, NICU, and ICU. Also analyzed insurers' clinical policies and contracts and successfully appealed using extensive research in the peer-reviewed medical literature. Expert in all Microsoft Office office suite software and several large database programs. Have experience with electronic medical records.Degree as Physician Assistant with seven years of clinical experience. Have held leadership and management positions and served as full-time trainer in hospital. Have published two research papers listed in the peer-reviewed medical literature and a chapter in a book on Medicine and Public Health.
