Appealing Observation Level of Care Denials
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. Much attention has been given to the clinical management of…
Requesting Fee Schedule Renegotiation
Requesting Fee Schedule Renegotiation Do your payers know about your quality improvements? Your commitment to quality may be focused on patient care but your payers benefit too. Your payers may even be willing to pay higher fees schedules for proven results resulting from quality of care programs. Why Not Ask? Appeal Solutions has developed a…
CASE STUDY: Appealing Insurance Claims Denied Due to no Coverage When Benefits Have Been Verified
At the time of patient admission, the Provider called the Insurance Company to verify policy benefits. An insurance representative confirmed that coverage was currently in effect. The insurance representative also stated that the insurance policy provided 80% coverage of usual and customary charges for the schedules procedure, with a $500 deductible and a $100,000 maximum.…
You Have a VOB, Now Make ‘Em Pay
A VOB Can Overturn Denied Claims, But Managed Care Contracts Should Strengthen Your Rights Managed care providers are slowly chipping away at the strength a verification of benefits holds during a claim appeal. Securing a verification of insurance benefits has long been the first step providers take to ensure payment of medical expenses. In addition…
Utilization Review Denials: Are Patients Abandoned or Offered Alternatives?
Carriers have a responsibility to provide detailed responses to utilization review requests. Further, when adverse determinations are given, many consumer protections require the carrier’s written denials to explain the clinical criteria supporting the decisions and provide appeal information. Unfortunately, many denials are silent on the issue of alternative covered options. Providers, case managers and patient…
Usual, Customary and (UN)Reasonable: Three Components of Asking for Higher Payment
Are insurers calculating usual, customary and reasonable correctly? In fact, do UCR reductions seem to result in unreasonable reimbursement? Do carriers balk at explaining the “reason” behind their supposedly reasonable adjustments? State and federal disclosure laws can be used to appeal for clarification on how the usual, customary and reasonable rates were calculated. It is…
This Costs an Arm and a Leg
Medical pricing has never been under as much scrutiny as it currently is. Medicare, HMO’s, worker’s comp carriers and repricing companies all seem to have come up with a different rate to pay for the same procedure — all without stepping foot into your office or facility. Most of these rates are arrived at by…
Online URAC Resources
In addition to AppealTraining, the following websites contain useful information about assessing insurers for URAC compliance: URAC Program Overview. This link takes you directly to the URAC page which explains the UR accreditation program and lists the carriers who have agreed to follow the standard. http://www.urac.org/about_complaint1.asp. Complaints filed with URAC regarding noncompliant members will be…
Using URAC To Curb Denials And Appeal Claims
The American Accreditation Healthcare Commission/URAC has established rigorous standards for utilization review which many carriers must follow. The standards were developed to ensure that appropriately trained clinical personnel conduct and oversee a timely and responsive utilization review process and that medical decisions are based on valid clinical criteria. The standards apply to accredited members of…
United Healthcare Out of Network Payments to go to Patient in 2007
United Healthcare has announced a new national policy to discontinue direct payment to out of network providers. According to an article in the September 2006 issue of Private Payer News, the policy will be effective July 1, 2007. Under the “pay the enrollee program,” United Healthcare will direct out-of-network benefit checks to the insured member…
