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?…
A Day Late and a Dollar Short
Claims Denied Due To Failure To Timely File Can Be Appealed Your business office missed the timely filing deadline by 30 days. The claim is filed and comes back denied. Now you have to make a decision – pursue the patient, write-off or appeal. If the coverage is managed care, your choices are narrowed to…
CASE STUDY: Suicide Denials
A medical provider has received an insurance denial due to a policy exclusion for self-inflicted injury. The patient was treated in the emergency room for the injury and then transferred to psychiatric care. To review the correctness of this action, the provider’s office obtained a copy of the carrier’s policy exclusion. The policy exclusion merely…
Subrogation’s Shaky Ground
The U.S. Supreme Court ruled against an insurance carrier’s attempt to enforce subrogation rights against a patient’s liability settlement. The decision may force health insurers into a quandary on whether to pay, deny or indefinitely stall the release of medical benefits on injury-related claims. Medical billers must carefully monitor such medical claims to insure that…
CASE STUDY: Subrogation & Coordination of Benefits
A Medical Provider treated the victim of a serious mowing accident which resulted in partial amputation. Insurance was verified at the time of patient admission at 80%-20% coverage with a $1,000 deductible. The medical bill, which totaled more that $75,000, was filed immediately after the patient’s discharge. The Carrier refused payment based on a subrogation…
Specialty-Specific Appeals: Demanding A Quality Review of Specialty Care Claims
Specialty care medical appeals often involve complex clinical information. Hours can be spent crafting a detailed explanation regarding the treatment provided and current specialty care standards. One of the ongoing challenges of specialty care appeals is demanding a professional review of the complex specialty care information such appeals involve. Specialty care appeal review requires insurers…
CASE STUDY: Shannon Clinic’s Battle With Managed Care
Do you ever feel like you are at war with insurance payers? Well, only on days that end with, “WHY?” As in “Why did you deny that” or “Why did they pay the bill at half the agreed rate?” We know how hard healthcare professionals are fighting this battle. So we thought we would provide…
Successful Denial Management Requires 2 Appeals
Most denials require two appeals for two reasons: first, insurance carriers do not always provide credentialed professionals for the initial review and second, insurance carriers often provide details in the Level I appeal response which may require further discussion. Level I appeal responses should be scrutinized for legal and contractual compliance. Some of the potential…
Are You Getting a Response From a Qualified Appeals Reviewer?
Urologists don’t recommend patients for open heart surgery. So should a urologists hired by an insurance company be allowed to make utilization review or appeal decisions related to cardiology treatment for an insurance company? Now that insurance companies have substantial input in regards to the course of treatment, it is imperative that reviews, particularly reviews…
Resisting Refund Requests
A Case-by-Case Analysis is Necessary Many medical providers and billing companies are seeing a spike in the number of refund requests received on commercial insurance accounts. Most prevalent among these requests involve third parties which carriers retain to audit accounts for incorrect payments. Due to the increased use of such outside auditing companies, providers and…
