This Costs an Arm and a Leg
Medical pricing has never been under as much scrutiny as it currently is. Medicare, HMO’s, worker’s comp carriers and repricing companies all seem to have come up with a different rate to pay for the same procedure — all without stepping foot into your office or facility. Most of these rates are arrived at by…
Online URAC Resources
In addition to AppealTraining, the following websites contain useful information about assessing insurers for URAC compliance: URAC Program Overview. This link takes you directly to the URAC page which explains the UR accreditation program and lists the carriers who have agreed to follow the standard. http://www.urac.org/about_complaint1.asp. Complaints filed with URAC regarding noncompliant members will be…
Using URAC To Curb Denials And Appeal Claims
The American Accreditation Healthcare Commission/URAC has established rigorous standards for utilization review which many carriers must follow. The standards were developed to ensure that appropriately trained clinical personnel conduct and oversee a timely and responsive utilization review process and that medical decisions are based on valid clinical criteria. The standards apply to accredited members of…
United Healthcare Out of Network Payments to go to Patient in 2007
United Healthcare has announced a new national policy to discontinue direct payment to out of network providers. According to an article in the September 2006 issue of Private Payer News, the policy will be effective July 1, 2007. Under the “pay the enrollee program,” United Healthcare will direct out-of-network benefit checks to the insured member…
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?…
A Day Late and a Dollar Short
Claims Denied Due To Failure To Timely File Can Be Appealed Your business office missed the timely filing deadline by 30 days. The claim is filed and comes back denied. Now you have to make a decision – pursue the patient, write-off or appeal. If the coverage is managed care, your choices are narrowed to…
CASE STUDY: Suicide Denials
A medical provider has received an insurance denial due to a policy exclusion for self-inflicted injury. The patient was treated in the emergency room for the injury and then transferred to psychiatric care. To review the correctness of this action, the provider’s office obtained a copy of the carrier’s policy exclusion. The policy exclusion merely…
Subrogation’s Shaky Ground
The U.S. Supreme Court ruled against an insurance carrier’s attempt to enforce subrogation rights against a patient’s liability settlement. The decision may force health insurers into a quandary on whether to pay, deny or indefinitely stall the release of medical benefits on injury-related claims. Medical billers must carefully monitor such medical claims to insure that…
CASE STUDY: Subrogation & Coordination of Benefits
A Medical Provider treated the victim of a serious mowing accident which resulted in partial amputation. Insurance was verified at the time of patient admission at 80%-20% coverage with a $1,000 deductible. The medical bill, which totaled more that $75,000, was filed immediately after the patient’s discharge. The Carrier refused payment based on a subrogation…
Specialty-Specific Appeals: Demanding A Quality Review of Specialty Care Claims
Specialty care medical appeals often involve complex clinical information. Hours can be spent crafting a detailed explanation regarding the treatment provided and current specialty care standards. One of the ongoing challenges of specialty care appeals is demanding a professional review of the complex specialty care information such appeals involve. Specialty care appeal review requires insurers…
