Appealing the Dual Diagnoses Dilemma
If patients suffered one illness or injury at a time, healthcare would be simplified. Most patients present a more complicated mix with multiple medical issues requiring treatment. Yet, carrier clinical review criteria and guidelines do not readily account for multiple diagnoses patients. Denials related to medical necessity, length of stay and/or beyond the specified treatment…
Getting Duplicate Claim Denials on Rebilled Claims?
You bill the claim. No response. You rebill the claim. This time, you get a response – a duplicate claim denial. Yes, you are still in the dark regarding what action was taken on the initial claim. Even worse, you spend 45 minutes on the phone only to find out that customer service can only…
Getting Around the Clean Claims Cop-out: Appealing Claim Deficiency Denials
Are your payers getting around prompt payment requirements using the clean claim cop-out? Although prompt payment is not tightly regulated on state and federal levels, many carriers avoid prompt payment by requiring claim detail above and beyond the standard identifying information. Particularly troublesome are carriers that drop “unclean claims” from their system without any notification…
Stopping Silent PPO Discounting: State Laws Recognize Silent PPO Unfairness
A number of state laws now set limits on Silent PPOs and seek to protect providers from unfair and un-negotiated preferred provider discounting. Silent PPO discounting refers to situations in which a managed care organization sells or rents the established network of negotiated fee schedule pricing and discount agreements to a third party. Organizations that…
Surgical Implant Appeals
Your patient is moving better, breathing better or perhaps hearing better because of a surgically implanted medical device. The problem? The insurer won’t pay full price for the device. This shortfall is affecting who gets to move better, breath better or hear better. Implanted device benefit calculation varies greatly from plan to plan. Often, payment…
Demanding Peer Review of Pediatric Denials
Pediatric care often involves aggressive medicine. Pediatric care givers are well known for their tenacity in providing their young patients with the future they deserve. Diagnostic medicine, too, is often made more complex with pediatric patients. The demands of pediatric care often are at odds with the constraints of black and white coverage terms. For…
Scope of Practice Appeals
Many healthcare providers, from advanced practice nurses to chiropractors, routinely receive denials due to the fact that the services and/or procedure performed is only covered when provided by a licensed medical doctor. These denials can often be successfully contested by citing state scope of practice information if the provider is acting within the scope of…
Dreaded Mail: New Fee Schedules
Fee schedule reductions may be on route to you today. If you are receiving a number of Notice of Fee Schedule Adjustment letters, here are some responses to consider: Make sure the carrier complies with state regulations governing the length of advance notice before fee schedule changes can be put into effect. Many carrier contract…
Demanding Peer Review of Assistant Surgeon Denials
“The decision to request that a physician assist at surgery remains the responsibility of the primary surgeon and, when necessary, should be a payable service.” This familiar statement is part of the ACS Physicians as Assistants at Surgery 2007 Study which is widely used to determine insurance coverage for assistant surgeons and other surgical assisting…
Now is the Time to Expand Your Verification of Benefits Form
Appealing Observation Level of Care Denials Under constant pressure to avoid unnecessary inpatient admission, observational care is growing in many regions. Further, many organizations are seeking ways to expand their observation care units to include more specialized personnel and equipment and intensive patient education programs. Are your payers rolling out new tactics to avoid releasing…
