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…

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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 –…

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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…

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Prompt Payment Appeals: Saying “What is Taking So Long” in Optimal Wording

Ah, Rejection. You try not to take it personal. After all, you can resubmit. But there is that little step in between that just fails to inspire interest. Research. Yes, the steps in working your claim rejection report look like this: Rejection. Research. Resubmit. However, the chore of working the claims which show up on…

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Prompt Payment Appeals: Saying “What is Taking So Long” in Optimal Wording

While some initial reports on ICD-10 claim processing have been favorable, many providers are experiencing payment delays and other revenue cycle challenges related to the coding transition. Both CMS and RelayHealth issued claims processing reports reflecting little change in denial rate metrics. According to the CMS report, denials for October, 2015 were about ten percent…

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ICD-10 & Cash Flow: What Denials Are Ahead?

ICD-10 promises to be one of the biggest medical coding updates in memory. Industry forecasters promise clinical documentation shortfalls, staff productivity losses, spotty vendor readiness, claim payment sluggishness and, at the end of this long line of performance pitfalls, we have been advised to expect double-to-triple increases in claim denials. Of course, preparations have been…

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ICD-10 Transition: Working With Your Referral Partners on Dual Coding

Don’t wait until the last minute to discuss ICD-10 with your referral partners. A good ICD-10 communication plan includes direct coordination with referral partners. Contacting your referrals partners now will allow you to start building an ICD-10 networking group for sharing information on payer readiness, vendor options and staff training and the information you mine…

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Unexplained Payment Variances: To Ignore or Appeal?

Medical claim payment variances come in all sizes and shapes. Some payment variance is justified and can be tracked down to modifiers, scheduled contract adjustments or newly-implemented coding guidance. However, some payment variances are more suspect. Some discounts are related to incorrect modifier application and/or usual, customary and reasonable adjustments should be scrutinized for accuracy.…

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How to Anticipate & Prepare For Medical Necessity Edits Before ICD-10 Hits

Denials are expected to increase 100 to 200 percent during the ICD-10 implementation scheduled for October 1, 2015. While many denials will be technical denials requiring minor coding corrections, some denials will likely pertain to newly developed medical necessity edits. Unfortunately, it is hard to anticipate where medical necessity edits will likely apply. ICD-10 implementation…

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Monitor and Escalate Prompt Payment and Remittance Transparency Violations Before ICD-10 Hits

Getting paid promptly by payers is an ongoing challenge. State and federal prompt payment laws have pushed carriers to enhance prompt payment performance. However, the ICD-10 transition set for Oct. 1, 2015 will likely impact payer claim processing time and is expected to at least double denials. Your ICD-10 planning should include a review of…

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