Who’s Reviewing Your Appeals? Man or Machine?
Appeals involve highly technical issues such as clinical guidelines, specialty coding standards, quality of care and contract requirements. It takes a highly qualified appeal reviewer to respond appropriately. However, carrier appeal responses fall short again and again. In fact, many carriers appear to send appeals through the same automated process which initially resulted in a…
Another Day in the Paradise of Managed Care Reimbursement
It has happened again… another reimbursement check and Explanation of Benefits (EOB) has arrived from a Managed Care Organization (MCO) with an amount less than what you believe is due to you under your MCO agreement. What do you do now? Start by asking yourself elementary questions similar to those questions used by service repairmen…
Negotiate a Better Managed Care Contract
The beginning of a new year is an excellent time to assess your need to strengthen your managed care contract agreements. Healthcare billing personnel often begin to view the provider–carrier relationship as an adversarial, often dysfunctional partnership, and improving that relationship may be low on a long priority list of urgent action items. However, the…
Managed Care Contracts: AKA Mangled Care Contracts
Why Should You Sign That Mangled Care Contract? No – the title does not have a typo in it – Don Self and Associates originated the term “Mangled Care” because it more accurately reflects the system than does the term “managed care”. Mangled Care can be an excellent system to be a part of, promote…
Will Managed Care Pass The Texas Test?
450 Texas Doctors Leave Aetna, Austin Hospital Officials Say Success Can Follow Walkout A group of more than 450 Texas physicians made headlines around the nation in October for their decision to drop out of Aetna’s U.S. Healthcare Physician Network. The New York Times calls it the biggest rebellion yet against a health insurance company.…
Lost Medical Records
Submitting medical records to insurance carriers for medical review is a time consuming but unavoidable medical billing activity. Many insurance carriers require documentation on any medical treatment which is above and beyond standard medical treatment protocols developed by the carriers and providers must be able to provide requested documentation in order to obtain payment. However,…
Drafting A Level I Appeal: Three Components of a Winning Appeal
Level I appeals need to be submitted timely. Medicare appeals must be filed within 120 days of the claim decision. Most commercial insurers require appeals within 180 days from the denial. These time constraints force medical providers into situations where the appeal must be filed before all information has been gathered regarding the claim. In…
Careful Assessment of Injury Claims Could Yield Higher Payoff
Emergency care presents a unique and often discussed problem to business office managers: Treatment must be rendered before ability to pay is assessed. When the coverage is Medicaid or Medicare, many providers are faced with a situation where the expected reimbursement is barely more, sometimes even less, than the cost of providing treatment. It is…
Demanding Fee Schedule Disclosure
Are your carriers forthcoming with fee schedule information? Incorrect payment appeals must be backed up with accurate fee schedule information. However, payment calculations may be affected by several variables including fee schedule modifications, bundling/coding logic and negotiated terms specific to your organization. Therefore, when a claim appears to be underpaid, your appeal may need to…
Are You Leaving Money On The Table?
Many Providers Using Available Fee Analyzer Resources Many practice administrators liken not appealing usual and customary denials to leaving money on the table. However, appealing denied benefits requires providers to justify charges – a task many have found problematic. Thanks in part to the explosion of managed care, medical reimbursement rates are now readily accessible…
