Appealing Coordination of Benefits Stalls And Denials
Start With Knowing Your State’s COB Requirements Multiple coverage is typically a favorable situation. However, insurers may delay payments due to coordination of benefits investigations. Further, denials and refund requests related to COB appear to be growing. COB investigation stalling on the part of the insurance carrier can frequently be resolved with a letter demanding…
Asking Insurers to Deviate from Medical Necessity Clinical Guidelines
Insurance carriers routinely cite evidence-based clinical guidelines when denying treatment authorization. However, a number of insurance industry resources confirm that insurance medical decision makers must consider the patient’s unique medical condition and should deviate from the clinical guidelines when appropriate. Requesting deviation from the guidelines will typically require an appeal focusing on the patient’s unique…
Bundling Denials Should Have Basis – Requesting Clarification
Bundling denials are highly problematic because various payors use different claim editing software to assess codes for compatibility. It becomes hard to determine why certain codes were bundled and what medical information might be persuasive in an appeal. For this reason, many bundling appeals should focus on seeking clarification regarding why the codes were bundled…
Obtaining Correct Benefit Information Prior to Treatment
Most healthcare organizations supplement online eligibility information by verifying benefits over the phone. Unfortunately, carriers routinely warn that benefit information obtained over the phone is “not a guarantee of payment.” One way to obtain more accurate benefit information is to take the verification of benefits process “one step further” by demanding Benefit Clarification Disclosure. Benefit…
U.S. District Court of Appeals Finds BCBS Direct Payment to Patients Violates Assignment of Benefits Law
The Blue Cross Blue Shield practice of mailing direct payment of out of network benefits to patients instead of assignment-holding providers was recently found to be a violation of Louisiana law, a ruling which casts into question the legality of millions of dollars in benefit payments which BCBS has sent directly to patients. BCBS has…
Increase Pay-up by Successfully Appealing Claim Denials
What if every time you had a patient in v-fib, you were allowed to shock him only once? What would your success rate be? Everyone in EMS knows that defibrillation often works only on the second, or even the third, shock. The same principle holds true when it comes to getting reimbursed for medical transportation.…
Precertification ICD-10 Training Recommendations
How can your organization anticipate and prepare for Payer ICD-10 pre-certification performance interruptions? We recommend developing a ICD-10 training program for pre-certification staff focused on Payer Performance Monitoring. Yes, precertification staff need the traditional elements of basic ICD-10 role-based training, However, consider adding the following Payer Performance Monitoring initiatives to your precertification training session: Impact…
Physician Role in Patient Advocacy: Getting to YES in Peer Review
Physicians often lament the days of yore when treatment decisions were made in the exam room and not the insurance company board room. However, a healthcare consultant who specializes in assisting healthcare organization secure coverage for new medical technology says physicians still have a say in individual coverage decisions. Mary Corkins, Founder of The Reimbursement…
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.…
An Ounce of Appeal is Worth a Pound of Payment
The health care hue and cry grows louder everyday. Medical and mainstream publications are filled with stories focusing on the barriers doctors and hospitals face in getting paid in today’s health care environment. Precertification, managed care and tight timely filing deadlines are just some of the hurdles medical professionals must finesse when seeking reimbursement. And…
