August 10, 2010

Greetings {ContactName|Appeal Letter Subscriber},

Confusion Ahead...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. . . .

Continue reading at AppealLettersOnline.com

The Patient Protection and Affordable Care Act (PPACA) interim rules take effect Sept. 24th. . .What does it mean for you?

AppealLettersOnline Featured Letters

We've added and updated the following letters to cite PPACA-related patient protections which are effective Sept. 24:

  • Pre-existing Conditions - The PPACA Patient's Bill of Rights prohibits most group health plans and policies from applying pre-existing conditions exclusions to children under age 19.  Our Pre-existing Condition Appeal letter has been updated to cite provisions of the pre-existing condition regulation.
  • Maximum Benefits Exhausted - The PPACA Patient's Bill of Rights prohibits the use of lifetime limits in all health plans and insurance policies issued or renewed on or after September 23. Our Maximum Benefits Exhausted Appeal letter demands disclosure of what type of maximum is being applied and cites the PPACA limitation on lifetime limits.

Access these appeal letters at AppealLettersOnline.com

Using ERISA and PPACA To Win Appeals

Statistics show that insurance carriers tend to uphold their own denials.  Therefore, PPACA's appeal review protections requires carriers to disclose information used to make decisions and to provide external review to assure impartial decision-making.

The two protections work together to bring more transparency and impartiality to appeal review.

We have developed an appeals training program for Using ERISA and PPACA to Win Appeals. This presentation is a three hour presentation specific to PPACA protections and how to incorporate the protections in appeals.  Tammy Tipton, President of Appeal Solutions, will discuss how to assert your rights when insurers deny or underpay claims.  Level I and Level II appeal responses will be discussed and legal protections related to appeal review will be explained.  Some of the PPACA changes to be discussed include the following:

  • Reform looks good on paper but will it work? How increased standardization and claim automation will affect denial management.
  • State and/or federal external appeal review law and demanding quality appeal review and response.  One of the key features of the PPACA is providing external review for all adverse benefit determinations.  Getting patients using external review requires high provider involvement.
  • ERISA claim procedure regulations and how to use ERISA to demand “inaccessible, ambiguous” claim file details
  • Coding appeals and demanding disclosure of claim benefit calculation and UCR methodology under PPACA reporting requirements.
  • Maximum Benefit and Preexisting Condition Appeals under PPACA.
  • How To Respond to Refund/Recoupment Response letters.
  • Communication: A-Make-Or-Break-You Skill under PPACA.

Cost of the presentation is $2500 plus airfare, hotel and transportation expenses for your area.  Training includes appeal letters customized for the client's specific denial issues.

Call 888-399-4925 and set up training for your denial management staff.

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