Resisting Refund Requests
A Case-by-Case Analysis is Necessary Many medical providers and billing companies are seeing a spike in the number of refund requests received on commercial insurance accounts. Most prevalent among these requests involve third parties which carriers retain to audit accounts for incorrect payments. Due to the increased use of such outside auditing companies, providers and…
Hospital Replaces Rebills With Appeals
Rebilling unpaid claims at 60 to 90 days has long been a rule of thumb in medical receivables management. However, a California hospital has found a much more appealing method of handling aged claims that resulted in an immediate drop in aged accounts. Presbyterian Intercommunity Hospital in Whittier, California, recently started appealing all unpaid claims…
Successful Rehab Appeals Depend on Medical Documentation
Medical professionals specializing in rehabilitation often find a paradox in insurance. Treatment is available for X number of visits as long as patient improvement can be demonstrated. Then, even if substantial progress is made, treatment is likely to be discontinued once the specified number of visits have been reached. If progress is not made, many…
Reserve the Right to Refuse to Treat Troublesome Patients
Most plan contracts forbid you to discriminate against a plan member for any reason. In other words, you must treat all plan members who seek treatment from you. This sounds fair on paper – but it could be a trap for the unsuspecting provider. By agreeing not to discriminate, you’re forced to treat patients you…
Refund Requests
Offer to Pay Back Incorrectly Paid Claims Once Other Payment Is Received Refund/recoupment requests must be responded to promptly. Most providers consider their options to be (1) return requested overpayment, or (2) request an appeal of the retroactive denial. However, one option, particularly appropriate for situations involving coordination of benefits, is to offer to pay…
CASE STUDY: Appealing Insurance Claims Denied on the Grounds of a Preexisting Condition
An Insurance Company denied a hospital’s claim based on policy language excluding coverage for pre-existing conditions. Upon request, the patient provided a copy of his policy and it was determined that pre-existing condition was defined as “any condition treated prior to the effective date of coverage.” Appeal Solutions’ first step on any pre-existing denial is…
CASE STUDY: Appealing Denials Based on Verification of Preauthorization of Coverage
At the time of patient admission, the Provider called the Insurance Company to verify policy benefits. An insurance representative confirmed that coverage was currently in effect and provided coverage details. A preauthorization was subsequently obtained from the case management department. However, after charges are filed, the carrier denies the claim based on a policy exclusion.…
PPO Discount Dispute Ruled Unrelated to ERISA
Often, medical providers end up agreeing to larger PPO discounts than they hoped to negotiate. Certain managed care organization are so large that non participation is not a viable option. However, the most unpleasant scenario is when large discounts are extended but the managed care organization does not live up to the terms of what…
CASE STUDY: Appealing Physician Assistant Denials Can Be Successful
A neurosurgeon frequently schedules a physician’s assistant to assist in surgical procedures. In addition, the neurosurgeon assists with pre and post-operative patient care. The physician’s assistant works under the constant supervision of the physician. In many situations, the PA’s involvement in the surgical procedure avoids the need to schedule an assistant surgeon for the procedure.…
Out of Network Emergency Care: Three Components of Asking For Higher Payment
Are insurers calculating your out-of-network emergency claim payments correctly? How do you know? Emergency care is one of the most protected areas of medical care. While scheduled procedures fall under a number of cost-containment features, emergency care is by definition not as easily managed by managed care. Further, there are a number of state and…
