Analyzing Overpayment Audit Results: How Accurate Is An Audit Extrapolation?
Overpayment recovery audits are becoming more commonplace. However, the process utilized by payers to calculate the overpayment amount is both poorly understood and rarely challenged. Healthcare consultant Frank Cohen of Frank Cohen and Associates is working to educate providers on the number manipulation game going on during overpayment audits. During a recent presentation on post-audit…
Three Steps To Coding Appeal Success: Improve Coding Appeals Now To Put Pressure On Payers To Divulge Coding Edits
Payer 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…
The 1000 Page Appeal Letter: Covering the Clinical Basis in Experimental/Investigational Appeals
When Attorney Jennifer Jaff appeals denied insurance claims, she uses boxes, not envelopes, for her appeals. Her average appeal often consumes more than 50 record-gathering, research and development hours. When ready for the box, some appeals can cover more than 1,000 pages. “If I send in a 1,000 page appeal and I get a denial…
Patient Balances: Are Carriers Calculating the Patient Payment Correctly?
Patient payments are on the rise. You know it and statistics support it. According to AthenaHealth PayerView 2012, the weighted Provider Collection Burden increased by 7 percent from 2010 – 2011 from 16.7 percent to 17.8 percent. Where is it headed in 2013? Higher, of course! Because the patient collection burden is frequently difficult to…
ICD-10 Implementation: Are You Fit To Be The Champion?
Change always needs a champion. Sometimes we get dragged into change clutching desperately to familiar habits. Other times, a champion emerges to create some enthusiasm and expectation about a new and better way. ICD-10 is the new and better way. According to a number of industry experts, ICD-10 addresses critical gaps and operating flaws inherent…
ICD-10 and Your Management Care Contract: Hold Harmless or Hold Accountable?
Your ICD-10 preparation checklist seems to be growing, right? Now, stories are beginning to surface that some healthcare organization are being asked to sign off on hold harmless terms related to the upcoming coding overhaul. Healthcare Finance News ran a story this month stating that health entities are negotiating ICD-10 hold-harmless clauses. Victoria Vance, an…
The 60-Day Appeal Review Standard: Getting Carriers To Answer Appeals
Appeal review deadlines vary from plan to plan and payer to payer. However, there are appeal deadlines applicable to most claims. A 60-day appeal response deadline is common among many types of plans. The Medicare Appeals Process applicable to Fee for Service claims requires that First Level Appeals, Redeterminations, be decided either by a letter,…
Denial Analysis Often Improves Healthcare Profitability
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.…
Using Disclosure Laws to Obtain Usual, Reasonable & Customary Denial Information
UCR denials are often mired in mystery. What does usual, reasonable and customary mean? How are the reimbursement rates calculated? Are payers using governmental entitlement program benefits as a basis for calculating UCR? What proof has the payer collected that actually demonstrates that the denied claim has been billed at a rate above the norm?…
ERA Transparency & Denials: How Medicaid Remittances May Clog Up The Workflow
Not every medical claim sails through the payer adjudication process. Every healthcare billing professional knows that some claims get dumped right back in your lap for “resubmission.” Here’s the tough question: How many hours does your staff spend on resubmission? And the other critical follow-up question: How much do you collect on resubmitted claims? The…
