Unexplained Payment Variances: To Ignore or Appeal?
Medical claim payment variances come in all sizes and shapes. Some payment variance is justified and can be tracked down to modifiers, scheduled contract adjustments or newly-implemented coding guidance. However, some payment variances are more suspect. Some discounts are related to incorrect modifier application and/or usual, customary and reasonable adjustments should be scrutinized for accuracy.…
How to Anticipate & Prepare For Medical Necessity Edits Before ICD-10 Hits
Denials are expected to increase 100 to 200 percent during the ICD-10 implementation scheduled for October 1, 2015. While many denials will be technical denials requiring minor coding corrections, some denials will likely pertain to newly developed medical necessity edits. Unfortunately, it is hard to anticipate where medical necessity edits will likely apply. ICD-10 implementation…
Monitor and Escalate Prompt Payment and Remittance Transparency Violations Before ICD-10 Hits
Getting paid promptly by payers is an ongoing challenge. State and federal prompt payment laws have pushed carriers to enhance prompt payment performance. However, the ICD-10 transition set for Oct. 1, 2015 will likely impact payer claim processing time and is expected to at least double denials. Your ICD-10 planning should include a review of…
Precertification and ICD-10: Does Your Organization Have Precertification Precision or Precertification Problems?
Denials are expected to increase 100-200% during the ICD-10 implementation scheduled for October, 2015. How many ICD-10 denials will be related to precertification problems? Unfortunately, frequently cited ICD-10 implementation studies have not include any analysis of denial sources. Therefore, it is important to know your current denial rate for denials related to “lack of preauthorization”…
Physician Role in Patient Advocacy: Getting to YES During Peer Review
Physicians often lament the days of yore when treatment decisions were made in the exam room and not the insurance company board room. However, a healthcare consultant who specializes in assisting healthcare organization secure coverage for new medical technology says physicians still have a say in individual coverage decisions. Mary Corkins, Founder of The Reimbursement…
3 Steps To Specialty Coding Appeal Success: Put Pressure on Payers to Divulge Specialty Coding Edits
Specialty-care coding edits confuse and confound the most experienced coders. However, challenging a payer’s coding determination often results in more confusion, more frustration and a single line of computer-generated insurer-speak such as “paid according to the plan or policy benefits.” Such explanations of benefits are little help and should be viewed as particularly unacceptable to…
What Works and What Fails Online For Your Review
When appealing denied claims, it is helpful to know what has worked in the past for similar types of appeals. Access to past decisions, however, is not widespread nor easily searched. However, the following two sites provide synopses on decisions related to higher level (Level II or above) appeals which provide a significant picture of…
ICD-10 Time Management: One Year, Many Goals
Deborah Grider has been waiting longer than most of us for ICD-10. As one of the top ICD-10 consultants in the country, she started studying ICD-10 years ago in preparation for what she felt would be a game changer in healthcare reimbursement. Last March, she had a schedule full of ICD-10 consulting projects ahead when…
Get Attached To Appeal Attachments
Yes, your appeal letter may be highly persuasive. You may feel victory is at hand! However, pause one moment before sending the appeal letter and consider the fact that almost every appeal letter can be improved with a related attachment. Attachments are often the “proof” that the insurance reviewer needs in order to overturn a…
Managed Care Contract Language and ICD-10: Top 6 ICD-10 Contract Readiness Questions
Do your managed care contract agreements protect your organization from poor quality claims processing and appeal review? The answer to this question will grow in importance with this year’s ICD-10 coding implementation. In fact, good contract language can be a key element to ICD-10 survival. Healthcare billing personnel often view the provider-carrier relationship as an…
