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.…
Never Talk to the Monkey When the Organ Grinder is Available
Don’t Underestimate the Importance of Directing Appeals to the Correct Person Insurance companies receive, review and uphold thousands of medical appeals each year. Should you be detered if you receive a letter stating your appeal letter was reviewed and the decision to deny payment was upheld? Absolutely not. If the argument you set forth in…
Who’s Reviewing Your Appeals? Man or Machine?
Appeals involve highly technical issues such as clinical guidelines, specialty coding standards, quality of care and contract requirements. It takes a highly qualified appeal reviewer to respond appropriately. However, carrier appeal responses fall short again and again. In fact, many carriers appear to send appeals through the same automated process which initially resulted in a…
Another Day in the Paradise of Managed Care Reimbursement
It has happened again… another reimbursement check and Explanation of Benefits (EOB) has arrived from a Managed Care Organization (MCO) with an amount less than what you believe is due to you under your MCO agreement. What do you do now? Start by asking yourself elementary questions similar to those questions used by service repairmen…
Negotiate a Better Managed Care Contract
The beginning of a new year is an excellent time to assess your need to strengthen your managed care contract agreements. Healthcare billing personnel often begin to view the provider–carrier relationship as an adversarial, often dysfunctional partnership, and improving that relationship may be low on a long priority list of urgent action items. However, the…
Managed Care Contracts: AKA Mangled Care Contracts
Why Should You Sign That Mangled Care Contract? No – the title does not have a typo in it – Don Self and Associates originated the term “Mangled Care” because it more accurately reflects the system than does the term “managed care”. Mangled Care can be an excellent system to be a part of, promote…
Will Managed Care Pass The Texas Test?
450 Texas Doctors Leave Aetna, Austin Hospital Officials Say Success Can Follow Walkout A group of more than 450 Texas physicians made headlines around the nation in October for their decision to drop out of Aetna’s U.S. Healthcare Physician Network. The New York Times calls it the biggest rebellion yet against a health insurance company.…
Lost Medical Records
Submitting medical records to insurance carriers for medical review is a time consuming but unavoidable medical billing activity. Many insurance carriers require documentation on any medical treatment which is above and beyond standard medical treatment protocols developed by the carriers and providers must be able to provide requested documentation in order to obtain payment. However,…
