Resources to Decrease Denied Medical Claims.
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Home | Articles & Case Studies

Articles & Case Studies

  Displaying Matches 49 thru 64 of 123 Found.  BACK NEXT
Subrogation's Shaky Ground
The U.S. Supreme Court ruled against an insurance carrier's attempt to enforce subrogation rights against a patient's liability settlement. The decision may force health insurers into a quandary on whether to pay, deny or indefinitely stall the release of medical benefits on injury-related claims. . . .more >>
CASE STUDY: Suicide Denials
A medical provider has received an insurance denial due to a policy exclusion for self-inflicted injury. The patient was treated in the emergency room for the injury and then transferred to psychiatric care. To review the correctness of this action, the provider’s office obtained a copy of the carrier’s policy exclusion. . . .more >>
A Day Late and a Dollar Short
Your business office missed the timely filing deadline by 30 days. The claim is filed and comes back denied. Now you have to make a decision - pursue the patient, write-off or appeal. . . .more >>
Using Disclosure Laws to Obtain Usual, Reasonable & Customary Denial Information
UCR denials are often mired in mystery. What does usual, reasonable and customary mean? How are the reimbursement rates calculated? Are payers using governmental entitlement program benefits as a basis for calculating UCR? What proof. . . .more >>
United Healthcare Out of Network Payments to go to Patient in 2007
United Healthcare has announced a new national policy to discontinue direct payment to out of network providers. According to an article in the September 2006 issue of Private Payer News, the policy will be effective July 1, 2007. Under the “pay the enrollee program,” United Healthcare will. . . .more >>
Using URAC To Curb Denials And Appeal Claims
The American Accreditation Healthcare Commission/URAC has established rigorous standards for utilization review which many carriers must follow. The standards were developed to ensure that appropriately trained clinical personnel conduct and oversee a timely and responsive utilization review process and. . . .more >>
Online URAC Resources
In addition to, the following websites contain useful information about assessing insurers for URAC compliance. . . .more >>
This Costs an Arm and a Leg
Medical pricing has never been under as much scrutiny as it currently is. Medicare, HMO's, worker's comp carriers and repricing companies all seem to have come up with a different rate to pay for the same procedure -- all without stepping foot into your office or facility. . . .more >>
Usual, Customary and (UN)Reasonable: Three Components of Asking for Higher Payment
Are insurers calculating usual, customary and reasonable correctly? In fact, do UCR reductions seem to result in unreasonable reimbursement? Do carriers balk at explaining the “reason” behind their supposedly reasonable adjustments. . . .more >>
Utilization Review Denials: Are Patients Abandoned or Offered Alternatives?
Carriers have a responsibility to provide detailed responses to utilization review requests. Further, when adverse determinations are given, many consumer protections require the carrier’s written denials to explain the clinical criteria supporting the decisions and provide appeal information. . . .more >>
You Have a VOB, Now Make 'Em Pay
Managed care providers are slowly chipping away at the strength a verification of benefits holds during a claim appeal. Securing a verification of insurance benefits has long been the first step providers take to ensure payment of medical expenses. . . .more >>
CASE STUDY: Appealing Insurance Claims Denied Due to no Coverage When Benefits Have Been Verified
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. The insurance representative also stated that the insurance policy. . . .more >>
Requesting Fee Schedule Renegotiation
Requesting Fee Schedule RenegotiationThis Fee Schedule Renegotiation Request letter easily initiates negotiations for fee schedule increases to offset ongoing investments in quality improvements. The letter provides some suggested wording which medical organizations can use to inform payers about quality of care initiatives and the need for fee schedule adjustments related to these efforts. . . .more >>
Appealing Observation Level of Care Denials
Under constant pressure to avoid unnecessary inpatient admission, observational care is growing in many regions. Further, many organizations are seeking ways to expand their observation care units to include more specialized personnel and equipment and intensive patient education programs. Much attention has been given to the clinical management of the observation unit. It is equally important to make sure the financial management is continually improved. We've conducted a round-up of online articles related to effective observational care reimburseme. . . .more >>
Now is the Time to Expand Your Verification of Benefits Form
Now is a good time to make sure your medical organization’s verification process is sufficiently thorough to identify the effects of pay-the-patient initiatives, high deductibles and tighter utilization review controls. . . .more >>
Demanding Peer Review of Assistant Surgeon Denials
Now is a good time to make sure your medical organization’s verification process is sufficiently thorough to identify the effects of pay-the-patient initiatives, high deductibles and tighter utilization review controls. . . .more >>

  Displaying Matches 49 thru 64 of 123 Found.  BACK NEXT