Do you ever feel like you are at war with insurance payers?
Well, only on days that end with, “WHY?” As in “Why did you deny that” or “Why did they pay the bill at half the agreed rate?”
We know how hard healthcare professionals are fighting this battle. So we thought we would provide you with a few tips straight a military genius, Napoleon Bonaparte, and a few ideas from one medical provider who is winning the managed care war.
Napoleon’s Guide To The Managed Care War
Napoleon used to say that the surgeon’s knife killed more people than his bayonet. Ouch! Surgery has come a long way since those days. Nowadays, patients don’t fear the surgeon’s knife as much as the HMO bureaucrat’s pencil.
The little dictator would have known how to fight this new war. His words seem to apply to the War With Managed Care. Here is a look at some of those words and how Shannon Clinic in San Angelo, Texas, is using those ideas to win the managed care war.
“10 people who speak make more noise than 10,000 who are silent.” – Napoleon Bonaparte
“Medical Providers who appeal denials get paid.” – Shannon Clinic
Managed care means denials. In 1999, Shannon Clinic decided to take action. They initiated a denial management program to address a growing number of denials and underpayments. Their goal was to appeal any denied or incorrectly paid claim over $50.00. Shannon Clinic is a multi-specialty group with more than 150 physicians located in South Texas. One of the biggest issues with their denial management program would be scale and efficiency; with a high patient volume and a denial rate averaging around 30 percent, they would be appealing a very high number of claims and needed to be able to do so quickly, professionally and effectively.
Shannon Clinic needed a software system to assist them generate appeals on a volume basis and track and monitor appeals as they went through the grievance review process. Power of Appeals was selected due to the extensive appeal template database (more than 1100 appeal letters) and due to the appeal management features such as automated letter generation, tracking, reporting and analysis.
Shannon Clinic was able to increase the denial overturn rate from 20 percent to 50 percent utilizing Power of Appeals. Their largest single recovery was over $12,000. Payment of this one claim alone utilizing the software paid for their initial software investment – $1500 for three users – with $10,000 to spare.
Power of Appeals is distributed by Appeal Solutions. Appeal Solutions specializes in appeal consulting and devotes every hour of every day to appealing medical claims through their denial outsourcing and onsite training programs. Appeal Solutions has helped hundreds of clients achieve overturn rates from 50 to 70 percent of denied claims. In the process, they have produced thousands of appeal letters which are included in the Power of Appeals software for medical providers to use on their problematic claims.
“To get information, it is necessary to seize the letters in the postal system, to question travelers. In one word, you have to look for it. Intelligence never comes by itself.” – Napoleon Bonaparte
“Know more than the insurance company at all times.” – Shannon Clinic
One of the benefits of Power of Appeals is that it allows Shannon Clinic to cite legal information to support their appeals.
“The content of the appeal letters really provide results, both in overturned claims and prompt responses from carriers. Some letters work better than others, depending on the denial reason, but they give us the means to appeal any type of denial and exercise our right to have denials reviewed and to be provided with proof to support their position,” said Peggy Adams, Business Office Department Supervisor.
Many of the appeal letter templates on the software address the insurance carrier’s duty to correctly process and support denials with documentation and even cite supporting legal citations. The letters cover almost any type of denial, including bundling, medical necessity, lack of precertification/referral, treatment limitations and many more. An appeal citing legal authority often will be answered more quickly, more thoroughly and more favorably by the insurance carrier. Further, many appeal denials are based on failure to timely submit the appeal to the appeals reviewer. Power of Appeals Software makes appealing so easy that Shannon Clinic has been able to submit appeals more quickly and avoid automatic denials based on failure to timely appeal.
Also, patient data can be imported into the software so that letters generated from the software already display patient data in the fields of the letter. This allows large facilities to move data efficiently.
“If you wish to be a success in the world, promise everything, deliver nothing.” – Napoleon Bonaparte
“This is Texas, not France. If you wish to be a success in medical recovery, appeal everything, deliver results.” – Shannon Clinic
Shannon Clinic’s many physicians are very aware of the business office’s expertise in appealing denials. As with many offices, the more success they have, the more they are asked to do. They originally had one person using the software but have added two users to tackle the growing workload in their department. Power of Appeals can be expanded at any time to accommodate more users. The software is also updated twice a year to provide users with changes in insurance regulations cited in the letters.
“Hesitation and half measures lose all in war.” – Napoleon Bonaparte
“We highly recommend Power of Appeals. The managed care war can only be won if providers are proactive and aggressive.” – Shannon Clinic
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