Medicare’s Slow Eradication of the “Improvement Coverage Standard”
CMS’s Ineffective Enforcement of Jimmo v Sebelius It has been seven years since the legal victory Jimmo v Sebelius. Jimmo v Seblius was a class action lawsuit alleging that Medicare payers were unfairly denying care based on an “Improvement Coverage Standard” which did not meet Medicare’s own coverage policy. Jimmo was considered a victory for…
Successful Strategies for Avoiding “No New Information” Denials
Unfortunately, one of the most frustrating and common denial responses from carriers are the words “Denial upheld. No new information submitted.” A No-New-Info appeal response is a clear signal that your organization may be submitting form letter appeals without making claim-specific customizations to the appeal letter. Appeal form letters have become routine in the industry…
The Reimbursement Rollercoaster: Do You Feel Bombarded by Managed Care Audits
About half of the U.S. adult population has at least one of ten chronic conditions. One in four adults has multiple chronic conditions. Further, About 34 percent of Medicare beneficiaries are enrolled in a Medicare Advantage plan this year. These statistics add up to a number of challenges for medical billing professionals. Managed care audits…
Appeal Your E/M “Level of Care” Denials By Asking For In-depth Coder Review
Evaluation and Management code selection often comes under intense scrutiny by payers. However, just as any other denial, these denials can be appealed. Payers provide little guidance regarding how E/M audits and denials are triggered. However, a well-worded appeal letter can seek information from the payer regarding their E/M reviews as well as information regarding…
Anthem’s New 90-day Timely Filing Requirement
Anthem has notified doctors and other providers that the timely filing window for professional claims is being shortened to 90 days. “Effective for all commercial and Medicare Advantage Professional Claims submitted to the plan on or after Oct. 1, 2019, your Anthem Blue Cross and Blue Shield (Anthem) Provider Agreement(s) will be amended to require…
Where Did The Provider Reps Go?
“Where is a payer provider rep when you need one?” Most practice administrators have a story about getting a payer performance issue resolved by an experienced, hands-on provider rep. If only more of them were experienced and hands-on. While many a practice administrator has bemoaned the lack of training or expertise of their assigned provider…
How to Use a Five-Part Approach to Appeals
Patient stories put the pulse in any healthcare communication – including appeals. Unfortunately, appeal letters generated from a healthcare organization often lack the persuasive impact that a first person appeal contains. However, customizing appeal letters to better present the patient story can often be accomplished by bringing in the patient’s personal narrative information from the…
Preauthorizations in Jeopardy: Online Payer Portals and Third Party Vendors Complicate Process
Preauthorization – a process created by payers to preemptively review treatment decisions – has long been seen as a bureaucratic hassle factor for practitioners. Despite its unpopularity, payers are far from making improvements and, in fact, many sources confirm that precertification problems are growing as payers experiment with changes to the unpopular and costly reimbursement…
Patient Stories: Do They Belong In Appeals?
Patient stories are the pulse in healthcare communication. “Open all meetings with a patient story—good or bad—and make sure the importance of patient centricity is the message communicated at all leadership meetings,” states the Press Ganey whitepaper “A Strategic Blueprint for Transformation Change,” released this month and available at PressGaney.com. Do appeal letters fall within…
It Took HOW LONG To Appeal That Denial?
One of the chief complaints about appealing denials for patients is that it takes too much time to do it well. Some might even say it takes too long to do it poorly thanks to poorly designed insurance company appeal processes. So, do we not do it? Do we do it half-heartedly with a simple…
