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How to Read, Analyze and Interpret a Summary Plan Description and Why the SPD is Important to OON Providers

Recorded Session | Thomas J. Force | From: Oct 22, 2020 - To: Dec 31, 2020
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Course Description

The presentation will discuss what a Summary Plan Description is. It will also describe in detail the sections and terms of the Summary Plan Description. It will highlight the most important information contained in the document and how that information can be used by the Provider, particularly out-of-network providers. The webinar will also discuss the appeal rights and procedures.

It will discuss what is a Schedule of Benefits, what needs to be in an SPD by law. It will point out the SPD provisions and sections which are important to familiarize yourself with such as the Glossary/Definition section, Deductibles, coinsurance, maximum OOP expenses, how to submit a claim, appeal procedures, and medically necessary v. investigational or experimental procedures.

It will further discuss the importance of the SPD to OON Providers including to determine medical necessity, eligible expenses, maximum allowable charge calculations and appeal rights, procedures and time periods. Finally, it will go through what a provider should do when they receive low or no payment on a claim.

Learning Objectives:-

  • Learn the difference between the Summary Plan Description and the Plan Document and the Insurance Certificate
  • Know what to look for in the SPD which is important to increase claim reimbursement
  • Learn how to determine what services are considered medically necessary
  • Learn the internal appeal rights afforded to the patient/provider
  • Know learn how eligible expenses are determined
  • Understand about external appeals and independent review of claims
  • Learn what the maximum allowed amounts are based on and calculated
  • Know the importance of requesting the plan documents
  • Know what documents and information they are entitled to from the insurance company and employer

Areas Covered in the Session:-

  • What is a Summary Plan Description?
  • What is a Plan Document?
  • What is an Insurance Certificate?
  • Why is the Summary Plan Description important to out-of-network providers in particular
  • How are allowed amounts determined?
  • What are the patients’/providers’ appeal rights?

Who Should Attend:-

  • In-Network and Out-of-Network Practitioners and Facilities
  • Office staff and Billing Managers
  • Physician
  • Healthcare Attorneys
  • Medical Billing Companies
  • Billing and Coding Specialists
  • Providers’ Office Staff
  • Hospital Revenue Cycle Staff