Preauthortizations in Jeopardy: Online Payer Portals and Third Party Vendors Complicate Process

Preauthorization – a process created by payers to preemptively review treatment decisions – has long been seen as a bureaucratic hassle factor for practitioners. Despite its unpopularity, payers are far from making improvements and, in fact, many sources confirm that precertification problems are growing as payers experiment with changes to the unpopular and costly reimbursement…

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Patient Stories: Do They Belong In Appeals?

Patient stories are the pulse in healthcare communication. “Open all meetings with a patient story—good or bad—and make sure the importance of patient centricity is the message communicated at all leadership meetings,” states the Press Ganey whitepaper “A Strategic Blueprint for Transformation Change,” released this month and available at PressGaney.com. Do appeal letters fall within…

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It Took HOW LONG To Appeal That Denial?

It Took HOW LONG To Appeal That Denial?

One of the chief complaints about appealing denials for patients is that it takes too much time to do it well. Some might even say it takes too long to do it poorly thanks to poorly designed insurance company appeal processes. So, do we not do it? Do we do it half-heartedly with a simple…

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Precision Medicine Reimbursement: Two Routes to Payment

Patients want personalized healthcare and healthcare organizations are looking for ways to provide it. However, the growth of medical options under the Precision Medicine category are being stalled by the ever present issues of reimbursement. Among the most highly utilized, genetic tests that can identify patients with a higher risk for cancer are hugely popular…

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Stop The Spread Of Denied Claims – Denial Prevention Can Work

A sudden spike in denied medical claims can clog up your entire financial spreadsheet, sending red ink into columns and rows where root causes hide and finger pointing starts. Just like your doctors often intone in the exam room – an ounce of prevention is (yes, really is) worth a pound of cure. In healthcare…

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How Do Mental Health Parity Laws Impact “Usual, Customary and Reasonable”

How Do Mental Health Parity Laws Impact “Usual, Customary and Reasonable” Usual, Customary and Reasonable Benefit Adjustments are often ambiguously applied to out-of-network claims and providers are left with little understanding of if the benefit calculation is accurate or not. While these balances are often the patient’s responsibility, many healthcare providers take on the advocacy…

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Successful Strategies for Avoiding “No New Information” Denials

Unfortunately, one of the most frustrating and common denial responses from carriers are the words “Denial upheld. No new information submitted.” A No-New-Info appeal response is a clear signal that your organization may be submitting form letter appeals without making claim-specific customizations to the appeal letter. Appeal form letters have become routine in the industry…

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Persistence Beyond Initial “No” Wins Appeals: Second in our “How I Won My Appeal” series

Medical billing professionals will often give the appeal process one shot. If the argument looks good, they will pursue the Level I appeal. Level II appeals, however, are often not pursued even if the Level I appeal letter was not reviewed carefully and the insurer failed to provide a good explanation for the denial. Many…

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Clinical Customizations Win Appeals: First in our “How I Won My Appeal” series

Medical billing professionals work hours developing effective appeal letters. However, often, the success stories which result from this effort go untold. At Appeal Solutions, we love to hear your appeal success stories and now plan to pass them along in an ongoing “How I Won My Appeal” series. As follows is a successful appeal scenario…

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Getting Some Legal with Your Medical Review: Indications That Independent Reviews Are Looking Into Clinical And Legal Issues

As medical care and reimbursement rules grow more complex, so does submitting effective appeals. You really need a doctor-lawyer conducting your appeals. But even if you did, does that guarantee your clinical and legal points would be given full consideration? The wide array of professionals currently involved in appeals – from doctors to medical billing…

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