Drafting A Level I Appeal: Three Components of a Winning Appeal
Level I appeals need to be submitted timely. Medicare appeals must be filed within 120 days of the claim decision. Most commercial insurers require appeals within 180 days from the denial. These time constraints force medical providers into situations where the appeal must be filed before all information has been gathered regarding the claim. In…
Careful Assessment of Injury Claims Could Yield Higher Payoff
Emergency care presents a unique and often discussed problem to business office managers: Treatment must be rendered before ability to pay is assessed. When the coverage is Medicaid or Medicare, many providers are faced with a situation where the expected reimbursement is barely more, sometimes even less, than the cost of providing treatment. It is…
Demanding Fee Schedule Disclosure
Are your carriers forthcoming with fee schedule information? Incorrect payment appeals must be backed up with accurate fee schedule information. However, payment calculations may be affected by several variables including fee schedule modifications, bundling/coding logic and negotiated terms specific to your organization. Therefore, when a claim appears to be underpaid, your appeal may need to…
Are You Leaving Money On The Table?
Many Providers Using Available Fee Analyzer Resources Many practice administrators liken not appealing usual and customary denials to leaving money on the table. However, appealing denied benefits requires providers to justify charges – a task many have found problematic. Thanks in part to the explosion of managed care, medical reimbursement rates are now readily accessible…
Less Than The Law Allows
State and Federal Laws Require EOB’s to Provide Specific Information Insurers call it an Explanation of Benefits. But many EOB’s read little more than “Claim denied” and leave the explanation to your own guesswork. A poorly written explanation of benefits may be more than just a nuisance; it may also be a violation of federal…
Assisting Your Out Of Network Patients with Network Inadequacy Appeals
Network adequacy/access to specialist standards are designed to make sure that health plans have an adequate network of providers within a specific geographic area and sufficient specialty care providers to provide quality care. These regulations often specify the types and number of primary care and specialty providers necessary, the distance enrollees have to travel to…
Insurance Recovery Requires Attitude
“Attitude is more important than facts.” This quote is from noted psychiatrist Karl Menninger who understood the vast importance about attacking a difficult situation with a strong mindset. In appealing denied insurance claims, you need to have the mindset that it is the insurance carrier’s burden to prove that the claim has been processed correctly…
Denial Analysis Tactics to Improve Reimbursement
What gets studied gets improved. This is one of the simplest management concepts yet one of the most challenging when it comes to ambiguous data. What is understood gets improved is the more accurate maxim for analyzing the ambiguous, often uncharted, sea of denial data being generated in the initial stages of healthcare denial management.…
Appealing Denied Claims Enhances Customer Service
Many providers view appealing denied medical claims as an unwanted, but necessary, function of back-end collections. An aggressive appeals program in your office can also be a tremendous boon to your practice’s reputation for extending exemplary customer service. Most patients recognize that a medical provider is going above the call of duty when they attempt…
Crime Victims Compensation Fund Offers Assistance to Victims of Crimes For Medical Treatment
Victims of violence and their families are forced to deal with emotional, physical, and, in most cases, the financial aftermath of a crime. Most states have created a fund to assist innocent victims of certain crimes and their family members when there is no other means of paying for crime-related income or medical losses. Use…
