Preauthorization Obtained But Not Honored: Utilization Review Standards Can Improve Preauthorization Appeals
When medical preauthorization is not honored, it is often up to the billing professional to determine why. Where should you start? First, know the law. State utilization review laws vary considerable. Some states require carrier to honor a preauthorization unless incorrect information was provided during the preauthorization process. Second, know the Utilization Review Accreditation Commission…
Sub-Specialty Peer Review Of Denials: Some Insurers Find Sub-Specialty Peer Reviewers In Short Supply
Access to sub-specialty peer reviewers is one of the most important protections related to quality appeal decisions. Sub-specialty peer reviewers have the expertise to initiate meaningful dialogue with providers related to both treatment decisions and applicable coverage limitations. Recent insurance industry comments related to healthcare reform indicate that peer reviewers are not always available, or…
Appeal Letter Access: Easy, Easy at AppealLettersOnline.com
Appeal letters are now easier to find and use. Most appeal letters require a very customized appeal. That is why AppealTraining.com has more than 1600 letter options. However, frequent situations require medical billing professionals to appeal quickly with minimal denial detail. AppealTraining.com introduces our Level I – Level II Basic Appeal Letters to address the…
The 1000 Page Appeal Letter: Covering the Clinical Bases In Experimental/Investigational Appeals
When Attorney Jennifer Jaff appeals denied insurance claims, she uses boxes, not envelopes, for her appeals. Her average appeal often consumes more than 50 record-gathering, research and development hours. When ready for the box, some appeals can cover more than 1,000 pages. “If I send in a 1,000 page appeal and I get a denial…
Post-Payment Audits and ERISA: Attorney encouraging demanding ERISA rights during recoupment
Post payment audit practices by commercial healthcare insurers are reaping millions of dollars for insurers. However, the process used by many of the largest carriers to identify and collect overpayments is the subject of a number of current class action lawsuits. If successful, these lawsuits may require insurers to provide more rigorous, claim-by-claim appeal review…
Who’s following New PPACA Regulations and Who’s Grandfathered: Improve Verification Process by Seeking PPACA Status
The Patient Protection and Affordable Care Act (PPACA) interim rules for Internal Claims and Appeals and External Review Processes, released last month, contain numerous changes aimed at simplifying appeals for health insurance plans and issuers, patients and providers. The interim rules are designed to enforce a standardized internal and external claim and appeal process and…
How Will External Review Expansion Affect You? External Review Under PPACA
How Will External Review Expansion Affect You? External Review Under PPACA Healthcare reform will make seeking external review of denied claims more accessible. The big question remains, “Will external review play a role in improving quality?” The Patient Protection and Affordable Care Act (ACA) protection of external appeal rights is aimed at reducing the troublesome…
Prior Authorization Denials: Demanding Review By Board Certified Physicians
Prior authorization denials deserve intense scrutiny. Obviously, appealing authorization denials greatly assists the patient access care their provider recommends. However, in a broader sense, prior authorization appeals is one of important ways that providers communicate, educate and maintain a sense of active partnership in healthcare delivery. State and federal laws likely dictate peer review of…
Timely Filing Appeal Improvement: Customize Your Timely Filing Appeals For Appeal Success
Timely filing appeals are simple and straightforward. In fact, the timely filing appeal letter is often merely a cover letter for timely filing documentation. A typical timely filing appeal briefly states that proof of timely filing information, such as patient account notes or electronic claim acknowledgment, is attached. Based on the documentation, payment is requested.…
Appeals Should Clarify Fuzzy Denials: Claims Often Fall in Claims Adjudication Grey Area
Some appeals succeed, others fail. Why? Unfortunately, many appeal letters fail because of THE CLAIMS ADJUDICATION GREY AREA. Health insurance policy language is notoriously unclear. Verification/Preauthorization requirements can be ambiguous. Payment methodology is inconsistent and contradictory. Medical Necessity is perhaps the most difficult term to clearly define. Even appeal procedures are often ambiguous and appeal…
