Precertification and ICD-10: Does Your Organization Have Precertification Precision or Precertification Problems?

Denials are expected to increase 100-200% during the ICD-10 implementation scheduled for October, 2015. How many ICD-10 denials will be related to precertification problems? Unfortunately, frequently cited ICD-10 implementation studies have not include any analysis of denial sources. Therefore, it is important to know your current denial rate for denials related to “lack of preauthorization”…

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Physician Role in Patient Advocacy: Getting to YES During 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…

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3 Steps To Specialty Coding Appeal Success: Put Pressure on Payers to Divulge Specialty Coding Edits

Specialty-care coding edits confuse and confound the most experienced coders. However, challenging a payer’s coding determination often results in more confusion, more frustration and a single line of computer-generated insurer-speak such as “paid according to the plan or policy benefits.” Such explanations of benefits are little help and should be viewed as particularly unacceptable to…

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What Works and What Fails Online For Your Review

When appealing denied claims, it is helpful to know what has worked in the past for similar types of appeals. Access to past decisions, however, is not widespread nor easily searched. However, the following two sites provide synopses on decisions related to higher level (Level II or above) appeals which provide a significant picture of…

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ICD-10 Time Management: One Year, Many Goals

Deborah Grider has been waiting longer than most of us for ICD-10. As one of the top ICD-10 consultants in the country, she started studying ICD-10 years ago in preparation for what she felt would be a game changer in healthcare reimbursement. Last March, she had a schedule full of ICD-10 consulting projects ahead when…

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Get Attached To Appeal Attachments

Yes, your appeal letter may be highly persuasive. You may feel victory is at hand! However, pause one moment before sending the appeal letter and consider the fact that almost every appeal letter can be improved with a related attachment. Attachments are often the “proof” that the insurance reviewer needs in order to overturn a…

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Managed Care Contract Language and ICD-10: Top 6 ICD-10 Contract Readiness Questions

Do your managed care contract agreements protect your organization from poor quality claims processing and appeal review? The answer to this question will grow in importance with this year’s ICD-10 coding implementation. In fact, good contract language can be a key element to ICD-10 survival. Healthcare billing personnel often view the provider-carrier relationship as an…

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Analyzing Overpayment Audit Results: How Accurate Is An Audit Extrapolation?

Overpayment recovery audits are becoming more commonplace. However, the process utilized by payers to calculate the overpayment amount is both poorly understood and rarely challenged. Healthcare consultant Frank Cohen of Frank Cohen and Associates is working to educate providers on the number manipulation game going on during overpayment audits. During a recent presentation on post-audit…

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Three Steps To Coding Appeal Success: Improve Coding Appeals Now To Put Pressure On Payers To Divulge Coding Edits

Payer coding edits confuse and confound the most experienced coders. However, challenging a payer’s coding determination often results in more confusion, more frustration and a single line of computer-generated insurer-speak such as “paid according to the plan or policy benefits.” Such explanations of benefits are little help and should be viewed as particularly unacceptable to…

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The 1000 Page Appeal Letter: Covering the Clinical Basis in Experimental/Investigational Appeals

When Attorney Jennifer Jaff appeals denied insurance claims, she uses boxes, not envelopes, for her appeals. Her average appeal often consumes more than 50 record-gathering, research and development hours. When ready for the box, some appeals can cover more than 1,000 pages. “If I send in a 1,000 page appeal and I get a denial…

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