The latest AMA Insurer Report Card found that 19.3 percent of claims are paid incorrectly.
Can you figure out which ones are which?
Often, it takes too much time and too many demands to properly audit your payer’s claim adjudication. Let’s all say it together: Insurance payment terms are too complex.
The Affordable Care Act (ACA) requires health insurers and group health plans to provide consumers with clear, consistent and comparable information about health plan benefits and coverage. Starting this year, all health plans and issuers will provide a Summary of Benefits and Coverage, along with a uniform glossary of terms, to shoppers and enrollees upon request and before they buy coverage. Therefore, it is time seeking disclosure of your payers newly drafted documents to see if any of the confusion, jargon and complex calculations were rewritten.
Kaiser Family Foundation conducted a recent poll asking responders to rate key features of the widely controversial ACA. The poll found that the requirement that plan provide short, easy to understand description of their benefits and coverage was the clear favorite. Sixty percent of the American people gave this requirement for greater transparency in health insurance benefits a very favorable rating, the only provision in the law to get such a rating from more than half of the polled.
AppealTraining.com has a number of appeal letters to assist providers with demanding benefit disclosure which is one way to obtain the Summary documents. The AppealTraining.com benefit disclosure letters cite the legal requirements, either state or federal law, requiring insurance carriers to disclose denial information. These letters can be used in situations where the payer is not providing disclosure of the denial information, including such supporting information as the rule, guideline or protocol on which the denial is based.
These letters are also very effective in appealing underpaid claims where disclosure of the benefit calculation method is the only way to audit benefits.
It is also a good time to take a look at the Managed Care Renegotiation Request letter. This letter sets the stage for contract renegotiations by putting the carrier on notice of the intent to renegotiation. This letter can be customized to reference specific contract clauses which you wish to update, including contract requirements for disclosure, appeal review and penalties in incorrect payments on claims.
See the AMA Insurer Report Card results at http://www.ama-assn.org/ama/pub/news/news/ama-health-insurer-report-card.page.
The KFF ACA poll results are at http://healthreform.kff.org/scan/2011/november/kaiser-november-health-tracking-poll-individual-elements-of-the-aca-popular-with-the-public.aspx.
Finally, all appeal letters referenced are available at AppealTraining.com.
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