Carrier Can Be Liable For Treatment Decisions
Recent Law Gives Citizens Right To Sue HMO The first lawsuit under the groundbreaking 1997 Texas law giving citizens the right to sue their Health Maintenance Organization for negligent treatment decisions was filed in October. The suit alleges that NYLCare Health Plans denied adequate hospitalization to Joseph Plocica, who suffered from severe depression and suicidal…
Appealing Lack of Timely Filing After a MSP Denial
CMS is undertaking a comprehensive effort to collect money owed to Medicare due to incorrect payments related to coordination of benefits. The result is that providers often learn of group health coverage by way of a letter requesting repayment of an incorrect Medicare payment. This puts providers in the tenable position of either writing off…
Mental Health Care Appeals: Seeking Compliance with the Mental Health Laws
State and Federal Mental Health Parity laws have given many behavioral health treatment providers hope regarding mental health care reimbursement. However, a Governmental Accounting Office report studied the effect of mental parity mandates and found that insurance carriers often modify policies to allow more equal coverage for mental health treatment but offset parity costs through…
Tactics To Recover Medicare Underpayments
Don’t Get Shortchanged When Treating Medicare Plan Patients Out of Network When you treat a patient who’s a member of a Medicare plan and you don’t have a contract with that plan, you expect to be paid the full amount you’re entitled to under Medicare. But many providers are getting shortchanged. Plans have begun to…
Medicare and Medical Necessity
The Social Security Act provision limiting Medicare coverage to medically necessary services and supplies uses broad language to reference this highly important coverage variable. Specifically, Section 1862(a)(1)(A) of the Social Security Act states the following: “Notwithstanding any other provision of this title, no payment may be made under part A or part B for any…
Medicare Names QIC for Physician Appeals
Medicare’s new Part B Fee-For-Service appeal procedures went into effect Jan. 1, 2006. As part of the new procedures, physicians may now file Level II appeals with Q2Administrators, the first independent contractor named for reviewing physician appeals. Q2Administrators is the Qualified Independent Contractor responsible for reviewing Part B and Durable Medical Equipment (DME) reconsideration requests.…
Medicare Appeal Changes Requires Early Submission of Documentation
The success of Medicare appeals frequently hinges on the quality of the supporting documentation. The early and thorough gathering of documentation is even more essential under the new Medicare Claims Appeal Procedures which were partially implemented May 1. One of the most significant changes to the appeal procedures is the creation of Qualified Independent Contractors.…
Submitting Peer-Reviewed Literature with Medical Necessity Appeals: My Evidence vs. Your Evidence
Submission of peer-reviewed literature can strengthen medical necessity and experimental/investigational appeals. Insurance companies have a duty to review information submitted during an appeal. Furthermore, an insurance company’s failure to properly review the clinical information can jeopardize their ability to legally defend their denial decision. In litigation involving a Prudential medical necessity denial, an attorney submitted…
CASE STUDY: Responding to Insurance Denials Due to Lack of Medical Necessity
A medical provider has received an insurance denial due to lack of medical necessity. To review the correctness of this action, the provider’s office obtains the carrier’s policy definition of medical necessity. According to the carrier, the medical necessity criteria includes any treatment which (1) is generally accepted by other medical practitioners for the treatment…
Seven Tips To A Successful Medical Necessity Appeal
AppealTraining.com has a number of letters citing state and federal disclosure laws which assist medical providers with demanding more complete information regarding denials. These letters are under the Topic: Benefit Reductions and the Subcategory: State Mandates in the AppealTraining.com Appeal Letter Repository and include a number of new state-specific disclosure letters. Request Immediate Peer-to-Peer Review.…
