Aetna Medical Director Denies Care Without Reading Submitted Medical Records
It is sort of rare to see any kind of “stunning admission” by an insurance giant. But this week’s headline about an Aetna Medical Director who made important decisions on claims without reading the medical records has been met with mounting frustration over lack of quality in payer review. In the CNN story, Dr. Anne-Marie…
Precision Medicine Reimbursement: Two Routes to Payment
Patients want personalized healthcare and healthcare organizations are looking for ways to provide it. However, the growth of medical options under the Precision Medicine category are being stalled by the ever present issues of reimbursement. Among the most highly utilized, genetic tests that can identify patients with a higher risk for cancer are hugely popular…
Stop The Spread Of Denied Claims – Denial Prevention Can Work
A sudden spike in denied medical claims can clog up your entire financial spreadsheet, sending red ink into columns and rows where root causes hide and finger pointing starts. Just like your doctors often intone in the exam room – an ounce of prevention is (yes, really is) worth a pound of cure. In healthcare…
How Do Mental Health Parity Laws Impact “Usual, Customary and Reasonable”
How Do Mental Health Parity Laws Impact “Usual, Customary and Reasonable” Usual, Customary and Reasonable Benefit Adjustments are often ambiguously applied to out-of-network claims and providers are left with little understanding of if the benefit calculation is accurate or not. While these balances are often the patient’s responsibility, many healthcare providers take on the advocacy…
Successful Strategies for Avoiding “No New Information” Denials
Unfortunately, one of the most frustrating and common denial responses from carriers are the words “Denial upheld. No new information submitted.” A No-New-Info appeal response is a clear signal that your organization may be submitting form letter appeals without making claim-specific customizations to the appeal letter. Appeal form letters have become routine in the industry…
Persistence Beyond Initial “No” Wins Appeals: Second in our “How I Won My Appeal” series
Medical billing professionals will often give the appeal process one shot. If the argument looks good, they will pursue the Level I appeal. Level II appeals, however, are often not pursued even if the Level I appeal letter was not reviewed carefully and the insurer failed to provide a good explanation for the denial. Many…
Clinical Customizations Win Appeals: First in our “How I Won My Appeal” series
Medical billing professionals work hours developing effective appeal letters. However, often, the success stories which result from this effort go untold. At Appeal Solutions, we love to hear your appeal success stories and now plan to pass them along in an ongoing “How I Won My Appeal” series. As follows is a successful appeal scenario…
Getting Some Legal with Your Medical Review: Indications That Independent Reviews Are Looking Into Clinical And Legal Issues
As medical care and reimbursement rules grow more complex, so does submitting effective appeals. You really need a doctor-lawyer conducting your appeals. But even if you did, does that guarantee your clinical and legal points would be given full consideration? The wide array of professionals currently involved in appeals – from doctors to medical billing…
Can Your Referral Providers Provide Payer Insight Ahead Of Contract Negotiations?
Congratulations, you have a healthcare referral partner. Now you can sit back and watch the waiting room fill up with new patients. Unfortunately, healthcare collaboration is not achieved without planning and communication. Therefore, as you begin a relationship with your referral partner – or even seek to strengthen a long-standing but low-volume referral partnership –…
ICD-10: Key Performance Indicators To Monitor
You feel pretty good about your ICD-10 implementation. Clean claims are getting filed daily and payments are rolling in. However, are you measuring and monitoring your ICD-10 impact or just keeping your fingers crossed? CMS is encouraging practices to be looking at several performance measures to make sure that any impact is quickly identified and…
