Whether you are completely new at appealing claim denials & underpayments or an experienced veteran, you'll still need to master the basics before continuing with the more advanced courses. The goal of this section is to help lay the groundwork for your education with some simple, yet important lessons surrounding appeals.

Medical providers who file appeals for patients provide a valuable service by resolving complex issues that patients can't resolve.  Often, however, carriers contest the providers’ rights to access pertinent claim review information and do not always recognize the provider’s rights to act on behalf of the patient. View this course and learn to establish your rights.

Seeking a verification of benefits is an important activity in today’s healthcare reimbursement process. However, not all verifications are equal. Learn how to improve the quality of the benefits information you obtain and incorporate verification of benefits confirmation into subsequent appeals.

A preapproved claim usually results in claim payment. Therefore, it is imperative that medical professionals demand a quality utilization review decision each time prior approval is sought. Appeal Solutions has extensive information on initiating appeal during utilization review.

Medical necessity appeals shape healthcare. Uncontested medical necessity denials result in a subtle shift in future treatment availability because insurers consistently apply medical necessity limitations. Effective medical necessity appeals bring to the carrier’s attention necessary variations in care, emerging efficacy issues, and situations revealing flaws in the day-to-day clinical application of the carrier’s written criteria. Thus, quality appeal review is critical and this course provides detailed tools for improving medical necessity appeals.

Insurance carriers exercise great control over both in- and out-of-network payment through fee schedules, usual, customary, and reasonable (UCR) limitations, and, more insidiously, computerized payment methodologies for applying internal bundling, downcoding, and other price controls.  Often, it is difficult to determine how a medical claim was paid and whether these payment policies are applied consistently and fairly across all claims. View this Course for more on appealing incorrect benefit calculations.

State specific prompt payment laws can be cited on stalled and pended claims. Learn all about prompt payment laws and state variations on the protections which apply to medical bills by viewing our Prompt Pay course and lessons.

Treatment Exclusions and Limitations have a direct impact on provider reimbursement. Unfortunately, denials related to policy or plan exclusions and limitations are often not appealed because providers do not have sufficient information regarding the policy or plan terms. This course provides information on approaching these types of appeals.

Many overpayments, such as duplicate payments or clearly erroneous payment amounts, are often easy to detect due to credit balances. More problematic, however, are refund requests received which request reimbursement for claims that appear to have been paid correctly by the carrier. Learn how to contest unsubstantiated refund/recoupment requests and how various regulations read in this course.

We have a number of specialty-specific medical appeal letters to assist our specialty care clients with appeals related to their specific practice areas. These letters focus on demanding peer-to-peer reviews and release of clinical review criteria applicable to specialty care. There is also a letter specific to each specialty that seeks to have coding denials reviewed by a credentialed coder with familiarity in specialty coding.

The Employee Retirement Income Security Act of 1974, also known as ERISA, is a federal law applicable to most employee benefit plans, excluding state and federal employees and religious organizations. The DOL estimates ERISA applies to more than 2.5 million group plans. Because these plans are exempt from most state regulations, it's important to know and use ERISA Claim Procedure Regulations and related protections in treatment verification and appeals.

Medicare appeal changes were implemented in 2005 that expanded providers’ rights and guaranteed prompt responses to appeals as well as qualified, independent reviews at upper-level appeals. Limitations have been added, however, that apply to the presentation of new evidence in high-level provider appeals, so it's important to gather and reference all applicable information in the early stages of the appeal.

Billing personnel often view the provider–carrier relationship as an adversarial, dysfunctional partnership, and improving that relationship may be low on a long urgent action priority list. However, the development of a mutually beneficial working relationship that fosters problem-solving can be very beneficial. This course provides extensive negotiation tips for contract improvements and tools to improve the ongoing contract compliance communication.