CASE STUDY: Shannon Clinic’s Battle With Managed Care
Do you ever feel like you are at war with insurance payers? Well, only on days that end with, “WHY?” As in “Why did you deny that” or “Why did they pay the bill at half the agreed rate?” We know how hard healthcare professionals are fighting this battle. So we thought we would provide…
Successful Denial Management Requires 2 Appeals
Most denials require two appeals for two reasons: first, insurance carriers do not always provide credentialed professionals for the initial review and second, insurance carriers often provide details in the Level I appeal response which may require further discussion. Level I appeal responses should be scrutinized for legal and contractual compliance. Some of the potential…
Are You Getting a Response From a Qualified Appeals Reviewer?
Urologists don’t recommend patients for open heart surgery. So should a urologists hired by an insurance company be allowed to make utilization review or appeal decisions related to cardiology treatment for an insurance company? Now that insurance companies have substantial input in regards to the course of treatment, it is imperative that reviews, particularly reviews…
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.…
