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…

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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…

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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…

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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…

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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…

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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…

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It Took HOW LONG To Appeal That Denial?

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…

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Aetna Medical Director Denies Care Without Reading Submitted Medical Records

Aetna Medical Director Denies Care Without Reading Submitted Medical Records

It is sort of rare to see any kind of “stunning admission” by an insurance giant. But this week’s headline about an Aetna Medical Director who made important decisions on claims without reading the medical records has been met with mounting frustration over lack of quality in payer review. In the CNN story, Dr. Anne-Marie…

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Precision Medicine Reimbursement: Two Routes to Payment

Patients want personalized healthcare and healthcare organizations are looking for ways to provide it. However, the growth of medical options under the Precision Medicine category are being stalled by the ever present issues of reimbursement. Among the most highly utilized, genetic tests that can identify patients with a higher risk for cancer are hugely popular…

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Stop The Spread Of Denied Claims – Denial Prevention Can Work

A sudden spike in denied medical claims can clog up your entire financial spreadsheet, sending red ink into columns and rows where root causes hide and finger pointing starts. Just like your doctors often intone in the exam room – an ounce of prevention is (yes, really is) worth a pound of cure. In healthcare…

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