Resources to Decrease Denied Medical Claims.
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Articles & Case Studies

  Displaying Matches 97 thru 112 of 123 Found.  BACK NEXT
ICD-10 and Your Management Care Contract: Hold Harmless or Hold Accountable?
Your ICD-10 preparation checklist seems to be growing, right?

Now, stories are beginning to surface that some healthcare organizations are being asked to sign off on hold harmless terms related to the upcoming coding overhaul. . . .
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ICD-10 Implementation: Are You Fit To Be The Champion?
Change always needs a champion.

Sometimes we get dragged into change clutching desperately to familiar habits. Other times, a champion emerges to create some enthusiasm and expectation about a new and better way. ICD-10 is the new and better way. According to a number of industry experts, ICD-10 addresses critical gaps and operating flaws inherent in ICD-9. Further, ICD-10 will allow for the capture of the disease specificity, severity, laterality and better supports exchange of health data between other countries and the United States.

However, the coding change will affect almost every area of the medical practice from scheduling to cash flow. Successful implementation will require extensive planning and coordination so that the many details, such as staff education, contract renegotiation and documentation improvement, can go on without workflow disruption. Implementation is further complicated by the need to continue to use ICD-9 for non-HIPAA entities such as workers compensation and auto insurance. Despite many cautionary articles, many industry experts report that most practices do not yet understand the scope of next year’s transition to ICD-10. . . .
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Patient Balances: Are Carriers Calculating the Patient Payment Correctly?
Patient payments are on the rise.

You know it and statistics support it. According to AthenaHealth PayerView 2012, the weighted Provider Collection Burden increased by 7 percent from 2010 – 2011 from 16.7 percent to 17.8 percent. Where is it headed in 2013?

Higher, of course!

Because the patient collection burden is frequently difficult to calculate, patients invariably question the balance. Further, some patient balances may not seem consistent with the information obtained during the verification and/or eligibility check. It is important to have a request letter seeking clarification from the carrier regarding the patient deductible/co-pay calculations. Read the rest of this article for just such a letter. . . .
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The 1000 Page Appeal Letter: Covering the Clinical Basis in Experimental/Investigational Appeals
The 1000 Page Appeal Letter:  Covering the Clinical Basis in Experimental/Investigational AppealsWhen 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.

"If I send in a 1,000 page appeal and I get a denial within ten days, I know they didn’t read it. That can be very frustrating. What you need to do then is file the second level of appeal and. . . .
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Three Steps To Coding Appeal Success: Improve Coding Appeals Now To Put Pressure On Payers To Divulge Coding Edits
Three Steps To Coding Appeal Success:  Improve Coding Appeals Now To Put Pressure On Payers To Divulge Coding EditsPayer coding edits confuse and confound the most experienced coders. However, challenging a payer's coding determination often results in more confusion, more frustration and a single line of computer-generated insurer-speak such as "paid according to the plan or policy benefits."

Such explanations of benefits are little help and should be viewed as particularly unacceptable to those practices concerned about the upcoming ICD-10 implementation and the likelihood that payer coding edits may greatly impact reimbursement in 2014.

Now is the optimum time to increase your demands that payers. . . .
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Analyzing Overpayment Audit Results: How Accurate Is An Audit Extrapolation?
Overpayment recovery audits are becoming more commonplace. However, the process utilized by payers to calculate the overpayment amount is both poorly understood and rarely challenged.

Healthcare consultant Frank Cohen of Frank Cohen and Associates is working to educate providers on the number manipulation game going on during overpayment audits. During a recent presentation on post-audit mitigation, Cohen explained that there are a number of different ways that auditors can bias the statistical analysis against the provider, resulting in a higher overpayment amount than might be statistically justifiable. . . .
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Managed Care Contract Language and ICD-10: Top 6 ICD-10 Contract Readiness Questions
Do your managed care contract agreements protect your organization from poor quality claims processing and appeal review? The answer to this question will grow in importance with this year's ICD-10 coding implementation.

In fact, good contract language can be a key element to ICD-10 survival. Healthcare billing personnel often view the provider-carrier relationship as an adversarial, often dysfunctional partnership. Unfortunately, improving that relationship is a daunting task.

However, ICD-10 implementation presents the opportunity to renew efforts to communicate with payers and seek improvement to the terms that define the partnership. Keep reading article for our Top 6 ICD-10 Contract Readiness Questions to ask. . . .
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Get Attached To Appeal Attachments
Yes, your appeal letter may be highly persuasive. You may feel victory is at hand! However, pause one moment before sending the appeal letter and consider the fact that almost every appeal letter can be improved with a related attachment.

Attachments are often the "proof" that the insurance reviewer needs in order to overturn a denial. Also, attachment can affect the review costs and time burden on the insurance carrier. Your attachment, not the appeal letter content, may be the driving factor in whether the appeal is processed by internally or submitted to a outside consultant with expertise in the area in question. . . . .
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ICD-10 Time Management: One Year, Many Goals
Deborah Grider has been waiting longer than most of us for ICD-10. As one of the top ICD-10 consultants in the country, she started studying ICD-10 years ago in preparation for what she felt would be a game changer in healthcare reimbursement. Last March, she had a schedule full of ICD-10 consulting projects ahead when word reached her while on a training assignment in the Virgin Islands about Congress's vote to delay the implementation again.

"Quite honestly, I have been involved with several implementation projects and, when they announced the delay. . . .
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What Works and What Fails Online For Your Review
When appealing denied claims, it is helpful to know what has worked in the past for similar types of appeals. Access to past decisions, however, is not widespread nor easily searched. However, the following two sites provide synopses on decisions related to higher level (Level II or above) appeals which provide a significant picture of how certain denials are reviewed . . .more >>
3 Steps To Specialty Coding Appeal Success: Put Pressure on Payers to Divulge Specialty Coding Edits
Specialty-care coding edits confuse and confound the most experienced coders. However, challenging a payer’s coding determination often results in more confusion, more frustration and a single line of computer-generated insurer-speak such as "paid according to the plan or policy benefits." Such explanations of benefits are little help and should be viewed as particularly unacceptable to those practices concerned about the upcoming ICD-10 implementation and the likelihood that payer ICD-10 coding edits may greatly impact reimbursement in 2015. . . .more >>
Physician Role in Patient Advocacy: Getting to YES During Peer Review
Physicians often lament the days of yore when treatment decisions were made in the exam room and not the insurance company board room. However, a healthcare consultant who specializes in assisting healthcare organization secure coverage for new medical technology says physicians still have a say in individual coverage decisions. Mary Corkins, Founder of The Reimbursement Group, assists healthcare organizations navigate the ins and outs of securing coverage for technology biologics and medical devices. She consults on the range of challenges new medical products face, from launch to collections and one of the unique services she provides is telephone support during physician peer reviews involving coverage decisions. Peer-to-Peer conferences, Corkins acknowledges, are "avoided like the plague" for a number of compelling reasons. Historically, peer-to-peer was not an across-the-board protection and not widely available for many denials. Further, companies that did provide peer-to-peer conference . . . .more >>
Precertification and ICD-10: Does Your Organization Have Precertification Precision or Precertification Problems?
Denials are expected to increase 100-200% during the ICD-10 implementation scheduled for October, 2015. How many ICD-10 denials will be related to precertification problems? Unfortunately, frequently cited ICD-10 implementation studies have not include any analysis of denial sources. Therefore, it is important to know your current denial rate for denials related to "lack of preauthorization" and "incorrect preauthorization" to have a baseline comparison. . . . .more >>
Monitor and Escalate Prompt Payment and Remittance Transparency Violations Before ICD-10 Hits
Getting paid promptly by payers is an ongoing challenge. State and federal prompt payment laws have pushed carriers to enhance prompt payment performance. However, the ICD-10 transition set for Oct. 1, 2015 will likely impact payer claim processing time and is expected to at least double denials. Your ICD-10 planning should include a review of. . . .more >>
How to Anticipate & Prepare For Medical Necessity Edits Before ICD-10 Hits
Denials are expected to increase 100 to 200 percent during the ICD-10 implementation scheduled for October 1, 2015. While many denials will be technical denials requiring minor coding corrections, some denials will likely pertain to newly developed medical necessity edits. Unfortunately, it is hard to anticipate where medical necessity edits will likely apply. . . .more >>
Unexplained Payment Variances: To Ignore or Appeal?
Medical claim payment variances come in all sizes and shapes. Some payment variance is justified and can be tracked down to modifiers, scheduled contract adjustments or newly-implemented coding guidance. However, some payment variances are more suspect. Some discounts are related to incorrect modifier application and/or usual, customary and reasonable adjustments should be scrutinized for accuracy. The trouble is in knowing what to appeal and what to accept as a correct adjustment. Once a payment variance is identified and the adjustment does not appear to be supported, action should be taken to determine if the payment adjustment is accurate. Here are some steps to consider when assessing payment variances . . . . more >>

  Displaying Matches 97 thru 112 of 123 Found.  BACK NEXT