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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Demanding HIPAA Compliance When Submitting Medical Records

Repeated submissions of medical records to carriers is a frustrating, often unnecessary, burden on medical providers. Unfortunately, when carriers are unable to locate mailed medical records, medical providers have little recourse other than duplicating the time consuming process of copying, preparing and shipping an often voluminous file. From a practical standpoint, medical billing professionals will…

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Contesting A Carrier’s Unreasonably Short Appeal Filing Deadline

Healthcare appeal letter development can involve extensive pre-submission ground work. Often, the necessary information for appeal letter development must be gathered from a number of sources including the patient and other medical providers. Detailed clinical appeals may require a review of medical literature. Even technical appeals may require information gathering from various organizational departments or…

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Using A Payer Appeal Form

Do you have a love-hate relationship with forms? Most insurance carriers have an appeal submission form to use when pursuing an appeal. The carrier may even have separate forms for providers versus patient appeals, appeal versus grievance issues and plan-specific or state-specific forms to collect the appropriate data for the claim in question. Don’t let…

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Preauthorization Process Improvement Tips That Work

Does your practice have certain procedures, medical devices and/or medications which require extra preauthorization effort? If so, it is likely that your preauthorization requests process can be improved with detailed focus on carrier utilization management compliance. Getting the insurance carrier to provide a quality preauthorization review process starts with asking three key compliance-focused questions during…

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Preauthorization Obtained But Not Honored: Utilization Review Standards Can Improve Preauthorization Appeals

When medical preauthorization is not honored, it is often up to the billing professional to determine why. Where should you start? First, know the law. State utilization review laws vary considerable. Some states require carrier to honor a preauthorization unless incorrect information was provided during the preauthorization process. Second, know the Utilization Review Accreditation Commission…

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Sub-Specialty Peer Review Of Denials: Some Insurers Find Sub-Specialty Peer Reviewers In Short Supply

Access to sub-specialty peer reviewers is one of the most important protections related to quality appeal decisions. Sub-specialty peer reviewers have the expertise to initiate meaningful dialogue with providers related to both treatment decisions and applicable coverage limitations. Recent insurance industry comments related to healthcare reform indicate that peer reviewers are not always available, or…

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Appeal Letter Access: Easy, Easy at AppealLettersOnline.com

Appeal letters are now easier to find and use. Most appeal letters require a very customized appeal. That is why AppealTraining.com has more than 1600 letter options. However, frequent situations require medical billing professionals to appeal quickly with minimal denial detail. AppealTraining.com introduces our Level I – Level II Basic Appeal Letters to address the…

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The 1000 Page Appeal Letter: Covering the Clinical Bases 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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Post-Payment Audits and ERISA: Attorney encouraging demanding ERISA rights during recoupment

Post payment audit practices by commercial healthcare insurers are reaping millions of dollars for insurers. However, the process used by many of the largest carriers to identify and collect overpayments is the subject of a number of current class action lawsuits. If successful, these lawsuits may require insurers to provide more rigorous, claim-by-claim appeal review…

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