eNewsletter: Reimbursement eNewsletter for the healthcare community

ISSUE 50 April 22, 2008















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? Find out how State and federal disclosure laws can be used to appeal for clarification on how the usual, customary and reasonable rates were calculated. Read this entire article...
AppealLettersOnline Featured Letter has added a number of appeal letters to assist users with appealing UCR appeals using this three point appeal approach. See the appeal letters under the Topic "Benefit Reductions" and the Subcategory "Miscellaneous" for general appeal letters. State-specific letter appear under the Topic "Benefit Reductions" and the Subcategory "State Mandates."
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New York Appeal Avoidance Audio Presentation
Our New York Appeals Avoidance Audio conference focuses on how to use state utilization review law and ERISA protections to demand prompt, professional precertification and verification of benefits. The 90-minute presentation will provide customized training on how to use legal information during precertification and verification of benefits and will include customized material for each participant.

Our New York Denial Avoidance Audio Conference will be Thursday, May 8. Cost of the presentation is $600 and includes a number of customized sample appeal letters and tracking tools designed specifically for the participating organization's use. Prior to the presentation, each participant may submit five representative denials for our analysis. Based on our review of this information, we will tailor the sample utilization review/VOB requests and appeal letters specific for your organizationís needs and present information during the audioconference on how to use the legal information to obtain precertifications and verification of benefits. Further, appeal tactics will be discussed when carriers are not in compliance with the state UR and VOB protections.

Denial Avoidance presentations are limited to 10 participants to allow each organization's specific claims to be addressed. Sign up early to secure participation and receive instructions on submitting your claim denials for review. Call 888-399-4925 to signup or for more information.