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Carrier Can Be Liable For Treatment Decisions The first lawsuit under the groundbreaking 1997 Texas law giving citizens the right to sue their Health Maintenance Organization for negligent treatment decisions alleges that NYLCare Health Plans denied adequate hospitalization. . . . more >> Out of Network Emergency Care: Three Components of Asking For Higher Payment Are insurers calculating your out-of-network emergency claim payments correctly? How do you know. . . .more >> CASE STUDY: Appealing Physician Assistant Denials Can Be Successful A neurosurgeon frequently schedules a physician's assistant to assist in surgical procedures. In addition, the neurosurgeon assists with pre and post-operative patient care. The physician's assistant works under the constant supervision. . . .more >> PPO Discount Dispute Ruled Unrelated to ERISA Often, medical providers end up agreeing to larger PPO discounts than they hoped to negotiate. Certain managed care organization are so large that non participation is not a viable option. However. . . .more >> CASE STUDY: Appealing Denials Based on Verification of Preauthorization of Coverage At the time of patient admission, the Provider called the Insurance Company to verify policy benefits. An insurance representative confirmed that coverage was currently in effect and provided coverage details. . . .more >> CASE STUDY: Appealing Insurance Claims Denied on the Grounds of a Preexisting Condition An Insurance Company denied a hospital's claim based on policy language excluding coverage for pre-existing conditions. Upon request, the patient provided a copy of his policy and it was determined that pre-existing condition was defined as. . . .more >> Refund Requests Refund/recoupment requests must be responded to promptly. Most providers consider their options to be (1) return requested overpayment, or (2) request an appeal of the retroactive denial. However. . . .more >> Reserve the Right to Refuse to Treat Troublesome Patients Most plan contracts forbid you to discriminate against a plan member for any reason. In other words, you must treat all plan members who seek treatment from you. This sounds fair on paper - but it could be a trap for the unsuspecting provider. . . .more >>

Successful Rehab Appeals Depend on Medical Documentation Medical professionals specializing in rehabilitation often find a paradox in insurance. Treatment is available for X number of visits as long as patient improvement can be demonstrated. Then, even if substantial progress is made. . . .more >> Hospital Replaces Rebills With Appeals CASE STUDY: Rebilling unpaid claims at 60 to 90 days has long been a rule of thumb in medical receivables management. However, a California hospital has found a much more appealing method of handling aged claims that resulted in an immediate drop in aged accounts. . . .more >> Resisting Refund Requests 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. . . .more >> 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. . . .more >> 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. . . .more >> 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. . . .more >> 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. . . .more >> 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. . . .more >>

  Displaying Matches 33 thru 48 of 123 Found.  BACK NEXT