Getting The Real Story On A Payer’s Fee Schedule
You have begged and pleaded and finally received the gold mine of information – the payer fee schedule! But, do you have the whole story about how the payer will, or won’t, pay? A complete fee schedule is more than just a list of the Current Procedural Terminology (CPT) codes and the associated contracted rate…
The Changing of the Code: Quarterly Code Changes May Require Appeal
Are your billing professionals keeping up with NCCI quarterly code changes? Now is the time to review the NCCI quarterly code change report. The NCCI code changes went into effect July 1 and include a number of retroactive code changes that allow you to resubmit claims for additional payment. Further, the NCCI database expanded with…
Refund/Recoupment: Following The Money
Settlement of a liability claim can take years and insurance carriers have a long memory. Unfortunately, providers get caught in the middle of the money muddle of who should pay and who should refund an overpayment. For this reason, providers need to review overpayment demands carefully. First, know how and if any managed care contract…
Are Payer Requests for Supplemental Billing Detail Rising?
Healthcare organizations and payers, large and small, are on the brink of full 5010 implementation. One of the touted benefits to both the healthcare providers and payers of 5010 is more detailed data useful for emerging reimbursement models. A number of healthcare organizations, particularly specialty and subspecialty providers, have identified a recent spike in requests…
What’s Covered and What’s Not? Partner With Your Patients to Demand Transparency
The latest AMA Insurer Report Card found that 19.3 percent of claims are paid incorrectly. Can you figure out which ones are which? Often, it takes too much time and too many demands to properly audit your payer’s claim adjudication. Let’s all say it together: Insurance payment terms are too complex. The Affordable Care Act…
Demanding HIPAA Compliance When Submitting Medical Records
Repeated submissions of medical records to carriers is a frustrating, often unnecessary, burden on medical providers. Unfortunately, when carriers are unable to locate mailed medical records, medical providers have little recourse other than duplicating the time consuming process of copying, preparing and shipping an often voluminous file. From a practical standpoint, medical billing professionals will…
Contesting A Carrier’s Unreasonably Short Appeal Filing Deadline
Healthcare appeal letter development can involve extensive pre-submission ground work. Often, the necessary information for appeal letter development must be gathered from a number of sources including the patient and other medical providers. Detailed clinical appeals may require a review of medical literature. Even technical appeals may require information gathering from various organizational departments or…
Using A Payer Appeal Form
Do you have a love-hate relationship with forms? Most insurance carriers have an appeal submission form to use when pursuing an appeal. The carrier may even have separate forms for providers versus patient appeals, appeal versus grievance issues and plan-specific or state-specific forms to collect the appropriate data for the claim in question. Don’t let…
Preauthorization Process Improvement Tips That Work
Does your practice have certain procedures, medical devices and/or medications which require extra preauthorization effort? If so, it is likely that your preauthorization requests process can be improved with detailed focus on carrier utilization management compliance. Getting the insurance carrier to provide a quality preauthorization review process starts with asking three key compliance-focused questions during…
Preauthorization Obtained But Not Honored: Utilization Review Standards Can Improve Preauthorization Appeals
When medical preauthorization is not honored, it is often up to the billing professional to determine why. Where should you start? First, know the law. State utilization review laws vary considerable. Some states require carrier to honor a preauthorization unless incorrect information was provided during the preauthorization process. Second, know the Utilization Review Accreditation Commission…
