Scope of Practice Appeals
Many healthcare providers, from advanced practice nurses to chiropractors, routinely receive denials due to the fact that the services and/or procedure performed is only covered when provided by a licensed medical doctor. These denials can often be successfully contested by citing state scope of practice information if the provider is acting within the scope of…
Dreaded Mail: New Fee Schedules
Fee schedule reductions may be on route to you today. If you are receiving a number of Notice of Fee Schedule Adjustment letters, here are some responses to consider: Make sure the carrier complies with state regulations governing the length of advance notice before fee schedule changes can be put into effect. Many carrier contract…
Demanding Peer Review of Assistant Surgeon Denials
“The decision to request that a physician assist at surgery remains the responsibility of the primary surgeon and, when necessary, should be a payable service.” This familiar statement is part of the ACS Physicians as Assistants at Surgery 2007 Study which is widely used to determine insurance coverage for assistant surgeons and other surgical assisting…
Now is the Time to Expand Your Verification of Benefits Form
Appealing Observation Level of Care Denials Under constant pressure to avoid unnecessary inpatient admission, observational care is growing in many regions. Further, many organizations are seeking ways to expand their observation care units to include more specialized personnel and equipment and intensive patient education programs. Are your payers rolling out new tactics to avoid releasing…
Appealing Observation Level of Care Denials
Appealing Observation Level of Care Denials Under constant pressure to avoid unnecessary inpatient admission, observational care is growing in many regions. Further, many organizations are seeking ways to expand their observation care units to include more specialized personnel and equipment and intensive patient education programs. Much attention has been given to the clinical management of…
Requesting Fee Schedule Renegotiation
Requesting Fee Schedule Renegotiation Do your payers know about your quality improvements? Your commitment to quality may be focused on patient care but your payers benefit too. Your payers may even be willing to pay higher fees schedules for proven results resulting from quality of care programs. Why Not Ask? Appeal Solutions has developed a…
CASE STUDY: Appealing Insurance Claims Denied Due to no Coverage When Benefits Have Been Verified
At the time of patient admission, the Provider called the Insurance Company to verify policy benefits. An insurance representative confirmed that coverage was currently in effect. The insurance representative also stated that the insurance policy provided 80% coverage of usual and customary charges for the schedules procedure, with a $500 deductible and a $100,000 maximum.…
You Have a VOB, Now Make ‘Em Pay
A VOB Can Overturn Denied Claims, But Managed Care Contracts Should Strengthen Your Rights Managed care providers are slowly chipping away at the strength a verification of benefits holds during a claim appeal. Securing a verification of insurance benefits has long been the first step providers take to ensure payment of medical expenses. In addition…
Utilization Review Denials: Are Patients Abandoned or Offered Alternatives?
Carriers have a responsibility to provide detailed responses to utilization review requests. Further, when adverse determinations are given, many consumer protections require the carrier’s written denials to explain the clinical criteria supporting the decisions and provide appeal information. Unfortunately, many denials are silent on the issue of alternative covered options. Providers, case managers and patient…
Usual, Customary and (UN)Reasonable: Three Components of Asking for Higher Payment
Are insurers calculating usual, customary and reasonable correctly? In fact, do UCR reductions seem to result in unreasonable reimbursement? Do carriers balk at explaining the “reason” behind their supposedly reasonable adjustments? State and federal disclosure laws can be used to appeal for clarification on how the usual, customary and reasonable rates were calculated. It is…
