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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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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