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Prior Authorization Denials: Demanding Review By Board Certified Physicians

Prior authorization denials deserve intense scrutiny.

Obviously, appealing authorization denials greatly assists the patient access care their provider recommends. However, in a broader sense, prior authorization appeals is one of important ways that providers communicate, educate and maintain a sense of active partnership in healthcare delivery.

State and federal laws likely dictate peer review of denials. But peer review may be defined differently by different carriers. . . .

Continue reading this article at AppealLettersOnline.com

Learn what the Patient Protection and Affordable Care Act (PPACA) interim rules can do to improve your profitability. . . . Upcoming Audioconference: 25 Proven Appeal Letters and Using PPACA For Today's Appeals.

AppealLettersOnline Featured Letters

We have a number of URAC appeal letters which cite the above referenced protections. Subscribe to AppealLettersOnline.com for instant access to the following:

• Peer-to-Peer Conversation Appeal
• Lack of Timely Decision Appeal
• Lack of Written Decision Appeal
• Appeals Consideration Appeal
• Lack of Appeal Response Appeal
• Records Request Response Appeal
• Lack of One Day Response Appeal

These letters can be used for utilization management appeals. They are also effective for claim denials in related to a preauthorization denial in which the standards do not appear to have been following prior to treatment.

Access these appeal letters at AppealLettersOnline.com

Fast Track To Appeal Success - Two Upcoming 90-Minute Appeals Training Audioconferences

"Denial upheld. There is no new information in your appeal."

This is an all-to-frequent response to most medical claim appeals but it doesn’t have to be the final word.

We have two upcoming appeals audioconferences featuring our most successful appeal letters and how and why they work.

25 Proven Appeal Letters and Using PPACA For Today's Appeals - Presentation and Review of 25 Level I and Level II Appeal Letters which are designed to easily appeal all denials and demand a detailed response from insurers regarding nonpayment. Proven Strategies for Level II appeal customizations, denial prevention and what to do when appeal efforts fail will also be discussed as well as how PPACA will affect appeal review.

Date, Time and Cost:  Join us via audioconference on either October 12 or November 16 at 11 CST. Participation is $247.

"You have got to cite compliance information in appeals. When the law is in your favor, let carriers know. When the law demands disclosure of the denial information, peer review and external review, you shouldn’t have to ask twice," said Tipton, president of Appeal Solutions Inc. and author of several denial management products and publications.

PPACA, ERISA regulations and state laws contain a number of protections related to inappropriate delays and denials. Many medical providers do not understand how the PPACA, ERISA and state law work in conjunction to the benefit of both provider and patient. The upcoming audioconference will provide appeal instructions and 25 appeal letter templates covering the most common denial types such as incorrect payment, coding, medical necessity, maximum benefits, eligibility/coordination, timely filing and slow payment.

"Providers may mistakenly think their only protections are those spelled out in the managed care contract. Managed care contracts were written by the carriers. State and federal law go much further in demanding quality appeal review," said Tipton.

Sign up for the 90-minute audio presentation today. Find out more about this audio presentation.

Space is limited - Call 888-399-4925 today to register your staff to participate in this audioconference or order a CD Recording.