ICD-10 and Your Management Care Contract: Hold Harmless or Hold Accountable?

Your ICD-10 preparation checklist seems to be growing, right? Now, stories are beginning to surface that some healthcare organization are being asked to sign off on hold harmless terms related to the upcoming coding overhaul. Healthcare Finance News ran a story this month stating that health entities are negotiating ICD-10 hold-harmless clauses. Victoria Vance, an…

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The 60-Day Appeal Review Standard: Getting Carriers To Answer Appeals

Appeal review deadlines vary from plan to plan and payer to payer. However, there are appeal deadlines applicable to most claims. A 60-day appeal response deadline is common among many types of plans. The Medicare Appeals Process applicable to Fee for Service claims requires that First Level Appeals, Redeterminations, be decided either by a letter,…

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Denial Analysis Often Improves Healthcare Profitability

What gets studied gets improved. This is one of the simplest management concepts yet one of the most challenging when it comes to ambiguous data. What is understood gets improved is the more accurate maxim for analyzing the ambiguous, often uncharted, sea of denial data being generated in the initial stages of healthcare denial management.…

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Using Disclosure Laws to Obtain Usual, Reasonable & Customary Denial Information

UCR denials are often mired in mystery. What does usual, reasonable and customary mean? How are the reimbursement rates calculated? Are payers using governmental entitlement program benefits as a basis for calculating UCR? What proof has the payer collected that actually demonstrates that the denied claim has been billed at a rate above the norm?…

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ERA Transparency & Denials: How Medicaid Remittances May Clog Up The Workflow

Not every medical claim sails through the payer adjudication process. Every healthcare billing professional knows that some claims get dumped right back in your lap for “resubmission.” Here’s the tough question: How many hours does your staff spend on resubmission? And the other critical follow-up question: How much do you collect on resubmitted claims? The…

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Getting The Real Story On A Payer’s Fee Schedule

You have begged and pleaded and finally received the gold mine of information – the payer fee schedule! But, do you have the whole story about how the payer will, or won’t, pay? A complete fee schedule is more than just a list of the Current Procedural Terminology (CPT) codes and the associated contracted rate…

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The Changing of the Code: Quarterly Code Changes May Require Appeal

Are your billing professionals keeping up with NCCI quarterly code changes? Now is the time to review the NCCI quarterly code change report. The NCCI code changes went into effect July 1 and include a number of retroactive code changes that allow you to resubmit claims for additional payment. Further, the NCCI database expanded with…

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Refund/Recoupment: Following The Money

Settlement of a liability claim can take years and insurance carriers have a long memory. Unfortunately, providers get caught in the middle of the money muddle of who should pay and who should refund an overpayment. For this reason, providers need to review overpayment demands carefully. First, know how and if any managed care contract…

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Are Payer Requests for Supplemental Billing Detail Rising?

Healthcare organizations and payers, large and small, are on the brink of full 5010 implementation. One of the touted benefits to both the healthcare providers and payers of 5010 is more detailed data useful for emerging reimbursement models. A number of healthcare organizations, particularly specialty and subspecialty providers, have identified a recent spike in requests…

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What’s Covered and What’s Not? Partner With Your Patients to Demand Transparency

The latest AMA Insurer Report Card found that 19.3 percent of claims are paid incorrectly. Can you figure out which ones are which? Often, it takes too much time and too many demands to properly audit your payer’s claim adjudication. Let’s all say it together: Insurance payment terms are too complex. The Affordable Care Act…

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