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Dreaded Mail: New Fee Schedules Do you dread opening mail from payers these days? Fee schedule reductions may be on route to you today. If you are receiving a number of Notice of Fee Schedule Adjustment letters, we have some responses for you to use . . . .more >> Scope of Practice Appeals Many healthcare providers, from advanced practice nurses to chiropractors, routinely receive denials due to the fact that the services and/or procedure performed is only covered when provided by a licensed medical doctor. These denials can often be successfully contested by citing state scope of practice information if the provider is acting within the scope of the applicable medical license. . . .more >> Demanding Peer Review of Pediatric Denials Pediatric care often involves aggressive medicine. Pediatric care givers are well known for their tenacity in providing their young patients with the future they deserve. Diagnostic medicine, too, is often made more complex with pediatric patients. The demands of pediatric care often are at odds with the constraints of black and white coverage terms. . . .more >> Surgical Implant Appeals Your patient is moving better, breathing better or perhaps hearing better because of a surgically implanted medical device. The problem? The insurer won’t pay full price for the device. This shortfall is affecting who gets to move better, breath better or hear better. . . .more >> Stopping Silent PPO Discounting: State Laws Recognize Silent PPO Unfairness A number of state laws now set limits on Silent PPOs and seek to protect providers from unfair and unnegotiated preferred provider discounting. . . .more >> Getting Around the Clean Claims Cop-out: Appealing Claim Deficiency Denials Are your payers getting around prompt payment requirements using the clean claim cop-out? Although prompt payment is not tightly regulated on state and federal levels, many carriers avoid prompt payment by requiring claim detail above and beyond the standard identifying information. Particularly troublesome are carriers which. . . .more >> Getting Duplicate Claim Denials on Rebilled Claims? You bill the claim. No response. You rebill the claim. This time, you get a response – a duplicate claim denial. Yes, you are still in the dark regarding what action was taken on the initial claim. Even worse, you spend 45 minutes on the phone only to find out that customer service can only access the most recent submission. . . .more >> Appealing the Dual Diagnoses Dilemma If patients suffered one illness or injury at a time, healthcare would be simplified. Most patients present a more complicated mix with multiple medical issues requiring treatment. Yet, carrier clinical review criteria and guidelines do not readily account for multiple diagnoses patients. . . .more >>

Medicare Timely Filing The newly enacted Patient Protection and Affordable Care Act amends the timely fling requirements on Medicare Fee for Service claims to one calendar year after the date of service. Learn more about how this will affect your facility. . . . more >> Appeals Should Clarify Fuzzy Denials: Claims Often Fall in Claims Adjudication Grey Area Some appeals succeed, others fail. Why? Unfortunately, many appeal letters fail because of THE CLAIMS ADJUDICATION GREY AREA. . . . more >> Timely Filing Appeal Improvement: Customize Your Timely Filing Appeals For Appeal Success Timely filing appeals are simple and straightforward. In fact, the timely filing appeal letter is often merely a cover letter for timely filing documentation. A typical timely filing appeal briefly states that proof of timely filing information, such as patient account notes or electronic claim acknowledgement, is attached. Based on the documentation, payment is requested. However, a successful appeal always covers all three steps to appeal success: a demand for denial disclosure, reference to compliance information such as claim processing laws or contractual obligations and, finally. . . . more >> 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. . .more >> How Will External Review Expansion Affect You? External Review Under PPACA Healthcare reform will make seeking external review of denied claims more accessible. The big question remains, "Will external review play a role in improving quality?" The Patient Protection and Affordable Care Act (ACA) protection of external appeal rights is aimed at reducing the troublesome concerns of conflict of interest in medical decision making. The interim final regulations on appeals released in July outlines expansive new external review requirements. . . .more >> Who’s following New PPACA Regulations and Who’s Grandfathered: Improve Verification Process by Seeking PPACA Status PPACA appeal review regulations have some important protections meant to achieve review transparency and insure impartial decision-making. However, understanding which plans and policies must follow the new rules may be confusing. Appeal Solutions explains some of the upcoming changes and suggests how to make the important distinction between who is following the newly developed PPACA appeal process and who isn't. . . .more >> Post-Payment Audits and ERISA: Attorney encouraging demanding ERISA rights during recoupment Mr. Hufford of Pomerantz, Haudek, Grossman & Gross law firm speaks about the recoupment litigation involving BCBSRI and also references related litigation involving Aetna and United Healthcare. Hear his instructions on contesting recoupment efforts and also additional discussion regarding how class action litigation is being used to represent the large number of involved providers. . . . more >> The 1000 Page Appeal Letter: Covering the Clinical Bases In Experimental/Investigational Appeals When Attorney Jennifer Jaff appeals denied insurance claims, she uses boxes, not envelopes, for her appeals. Her average appeal often consumes more than 50 record-gathering, research and development hours. When ready for the box, some appeals can cover more than 1,000 pages. . . . more >>

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