eNewsletter: Reimbursement eNewsletter for the healthcare community

ISSUE 54 Sept 4, 2008























Five Sentences to Improve Your Appeal Letters
Do your carefully worded appeals result in  simple form letter responses? If so, it is likely that your appeals may need more forceful language regarding carrier appeal review and response requirements. Read our 5 sentences that will improve your appeal letters.
AppealLettersOnline Featured Letters
We have a number of new appeal letters that can be easily customized for specialty-care appeals. Please see the Topic: Specialty Care Appeal Review. The following four letters have been added to AppealLettersOnline to assist with cardiology appeals:

1. Request for Clinical Criteria - Neurology
2. Request for Coding Criteria – Neurology
3. Request for Neurology Peer Review
4. Request for Coding Credentials – Neurology

These letters can easily be updated to reference a different specialty care area. For assistance with adapting these letters to other specialties, members should post their specialty billing question in the forum area specific for their specialty.
Access these letters
Medical Necessity Appeals Audioconference
Our Audioconference, Medical Necessity Appeals and Demanding A Quality Review by the Payer, discusses your rights in regard to demanding a quality medical necessity appeal review. This 90-minute audioconference will be Thursday, October 2, at 11 a.m. CT.  Cost is $249.00 and includes 15 sample medical necessity and experimental/investigational appeal letters. Medical necessity appeals involve detailed discussions of a patient’s unique medical condition and how the specialty-specific treatment provided is the most appropriate, medically necessary option. Such appeals can take hours to properly develop. However, what assurance does a provider have that appeals reviewers will thoroughly review this detailed, patient specific, specialty-care information? We will provide 15 medical necessity and experimental/investigational appeal letters which focus on demanding the highest quality medical review at the insurance carrier. During the presentation, we will discuss how to demand that the appeal reviewer has appropriate credentials for the review. Medical necessity appeals rely on clinical issues and we will also discuss how to demand detailed review of the submitted medical documentation and how to seek review of any submitted peer-reviewed literature supporting treatment. We will discuss the provider’s rights to the insurance carrier’s internal clinical criteria, expert opinions and technical assessments and how to use and critique the applicability of such information in Level II appeals. Finally, we will look at insurance litigation which has criticized carrier review for failure to thoroughly review submitted information and discuss how to cite the carrier’s legal obligations in your appeals. Signup for this audioconference.