What Works and What Fails Online For Your Review

When appealing denied claims, it is helpful to know what has worked in the past for similar types of appeals. Access to past decisions, however, is not widespread nor easily searched.

However, the following two sites provide synopses on decisions related to higher level (Level II or above) appeals which provide a significant picture of how certain denials are reviewed.

Visit the Health and Human Services (HHS) website page for Medicare Appeals Council Decisions.

Visit the California Department of Managed Healthcare website for Independent Medical Review decisions.

Both sites have a search field to narrow content. The California Department of Managed Healthcare site has advanced search options allowing one to quickly find relevant decisions. The HHS site decisions disclose the name of the Medicare contractor which rendered the original decision. Therefore, payer-specific searches can be conducted at the HHS site while the California Department of Managed Healthcare decisions do not reference payer names.

To use the site for appeal research, you might want to review emergency decisions by searching “overturned denials” and “pain level” in order to review several scenarios in which a patient’s pain level is a determined factor in overturning a payer’s original decision to deny emergency care coverage.

The HHS site can also be searched for “statistical sample” in combination with other variables such as “observation,” “chest pain,” and “recoupment” for various decisions relevant to large balance denials involving multiple claims.

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