Less Than The Law Allows
State and Federal Laws Require EOB’s to Provide Specific Information Insurers call it an Explanation of Benefits. But many EOB’s read little more than “Claim denied” and leave the explanation to your own guesswork. A poorly written explanation of benefits may be more than just a nuisance; it may also be a violation of federal…
Assisting Your Out Of Network Patients with Network Inadequacy Appeals
Network adequacy/access to specialist standards are designed to make sure that health plans have an adequate network of providers within a specific geographic area and sufficient specialty care providers to provide quality care. These regulations often specify the types and number of primary care and specialty providers necessary, the distance enrollees have to travel to…
Insurance Recovery Requires Attitude
“Attitude is more important than facts.” This quote is from noted psychiatrist Karl Menninger who understood the vast importance about attacking a difficult situation with a strong mindset. In appealing denied insurance claims, you need to have the mindset that it is the insurance carrier’s burden to prove that the claim has been processed correctly…
Denial Analysis Tactics to Improve Reimbursement
What gets studied gets improved. This is one of the simplest management concepts yet one of the most challenging when it comes to ambiguous data. What is understood gets improved is the more accurate maxim for analyzing the ambiguous, often uncharted, sea of denial data being generated in the initial stages of healthcare denial management.…
Appealing Denied Claims Enhances Customer Service
Many providers view appealing denied medical claims as an unwanted, but necessary, function of back-end collections. An aggressive appeals program in your office can also be a tremendous boon to your practice’s reputation for extending exemplary customer service. Most patients recognize that a medical provider is going above the call of duty when they attempt…
Crime Victims Compensation Fund Offers Assistance to Victims of Crimes For Medical Treatment
Victims of violence and their families are forced to deal with emotional, physical, and, in most cases, the financial aftermath of a crime. Most states have created a fund to assist innocent victims of certain crimes and their family members when there is no other means of paying for crime-related income or medical losses. Use…
Appealing Coordination of Benefits Stalls And Denials
Start With Knowing Your State’s COB Requirements Multiple coverage is typically a favorable situation. However, insurers may delay payments due to coordination of benefits investigations. Further, denials and refund requests related to COB appear to be growing. COB investigation stalling on the part of the insurance carrier can frequently be resolved with a letter demanding…
Asking Insurers to Deviate from Medical Necessity Clinical Guidelines
Insurance carriers routinely cite evidence-based clinical guidelines when denying treatment authorization. However, a number of insurance industry resources confirm that insurance medical decision makers must consider the patient’s unique medical condition and should deviate from the clinical guidelines when appropriate. Requesting deviation from the guidelines will typically require an appeal focusing on the patient’s unique…
Bundling Denials Should Have Basis – Requesting Clarification
Bundling denials are highly problematic because various payors use different claim editing software to assess codes for compatibility. It becomes hard to determine why certain codes were bundled and what medical information might be persuasive in an appeal. For this reason, many bundling appeals should focus on seeking clarification regarding why the codes were bundled…
Obtaining Correct Benefit Information Prior to Treatment
Most healthcare organizations supplement online eligibility information by verifying benefits over the phone. Unfortunately, carriers routinely warn that benefit information obtained over the phone is “not a guarantee of payment.” One way to obtain more accurate benefit information is to take the verification of benefits process “one step further” by demanding Benefit Clarification Disclosure. Benefit…
