Prior Authorization Denials: Demanding Review By Board Certified Physicians
Prior authorization denials deserve intense scrutiny. Obviously, appealing authorization denials greatly assists the patient access care their provider recommends. However, in a broader sense, prior authorization appeals is one of important ways that providers communicate, educate and maintain a sense of active partnership in healthcare delivery. State and federal laws likely dictate peer review of…
Timely Filing Appeal Improvement: Customize Your Timely Filing Appeals For Appeal Success
Timely filing appeals are simple and straightforward. In fact, the timely filing appeal letter is often merely a cover letter for timely filing documentation. A typical timely filing appeal briefly states that proof of timely filing information, such as patient account notes or electronic claim acknowledgment, is attached. Based on the documentation, payment is requested.…
Appeals Should Clarify Fuzzy Denials: Claims Often Fall in Claims Adjudication Grey Area
Some appeals succeed, others fail. Why? Unfortunately, many appeal letters fail because of THE CLAIMS ADJUDICATION GREY AREA. Health insurance policy language is notoriously unclear. Verification/Preauthorization requirements can be ambiguous. Payment methodology is inconsistent and contradictory. Medical Necessity is perhaps the most difficult term to clearly define. Even appeal procedures are often ambiguous and appeal…
Medicare Timely Filing
The newly enacted Patient Protection and Affordable Care Act amends the timely fling requirements on Medicare Fee for Service claims to one calendar year after the date of service. The one-year filing deadline applies to any claims for services provided on or after January 1, 2010. Prior to PPACA, the regulations stated the service provider…
Appealing the Dual Diagnoses Dilemma
If patients suffered one illness or injury at a time, healthcare would be simplified. Most patients present a more complicated mix with multiple medical issues requiring treatment. Yet, carrier clinical review criteria and guidelines do not readily account for multiple diagnoses patients. Denials related to medical necessity, length of stay and/or beyond the specified treatment…
Getting Duplicate Claim Denials on Rebilled Claims?
You bill the claim. No response. You rebill the claim. This time, you get a response – a duplicate claim denial. Yes, you are still in the dark regarding what action was taken on the initial claim. Even worse, you spend 45 minutes on the phone only to find out that customer service can only…
Getting Around the Clean Claims Cop-out: Appealing Claim Deficiency Denials
Are your payers getting around prompt payment requirements using the clean claim cop-out? Although prompt payment is not tightly regulated on state and federal levels, many carriers avoid prompt payment by requiring claim detail above and beyond the standard identifying information. Particularly troublesome are carriers that drop “unclean claims” from their system without any notification…
Stopping Silent PPO Discounting: State Laws Recognize Silent PPO Unfairness
A number of state laws now set limits on Silent PPOs and seek to protect providers from unfair and un-negotiated preferred provider discounting. Silent PPO discounting refers to situations in which a managed care organization sells or rents the established network of negotiated fee schedule pricing and discount agreements to a third party. Organizations that…
Surgical Implant Appeals
Your patient is moving better, breathing better or perhaps hearing better because of a surgically implanted medical device. The problem? The insurer won’t pay full price for the device. This shortfall is affecting who gets to move better, breath better or hear better. Implanted device benefit calculation varies greatly from plan to plan. Often, payment…
Demanding Peer Review of Pediatric Denials
Pediatric care often involves aggressive medicine. Pediatric care givers are well known for their tenacity in providing their young patients with the future they deserve. Diagnostic medicine, too, is often made more complex with pediatric patients. The demands of pediatric care often are at odds with the constraints of black and white coverage terms. For…
