August 1, 2012

Greetings {ContactName|Appeal Letter Subscriber},

Prepayment Audits To Begin August 27th

Medicare Recovery Auditors will begin conducting prepayment reviews on certain types of claims that historically result in high rates of improper payments.

The reviews will focus on seven states with high populations of fraud- and error-prone providers: Florida, California, Michigan, Texas, New York, Louisiana and Illinois and four states with high claims volumes of short inpatient hospital stays: Pennsylvania, Ohio, North Carolina and Missouri.

This demonstration is part of the CMS effort to lower the error rate by preventing improper payments rather than the traditional "pay and chase" methods of looking for improper payment after they occur. The demonstration begins August 27, 2012.

A Special Open Door Forum on the Recovery Audit Prepayment Review Demonstration is set for August 9, 2012, from 2 to 4 p.m., ET.  You can participate by dialing 1-866-501-5502 and enter Conference ID 16834984.  More participation instructions and slides are expected to be posted at the following CMS.gov site:  https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Demonstrations.html


Using URAC Standards to Curb Denials and Appeal Claims

If you are having trouble getting timely decisions from insurance carriers, URAC has established standards for excellence in timely utilization review and has a number of important protections for patients and physicians.

Read this article at AppealLettersOnline.com for information on using URAC in your appeals.


AppealLettersOnline.com Featured Letters

The AppealLettersOnline.com Repository has seven letters designed to assist providers with appealing claims based on lack of URAC compliance by a carrier. These letters directly quote URAC standards related to requirements for peer-to-peer conversation subsequent to any denial, timely decision making on UR and appeal requests and specifications for providing sufficient detail in written denials. There is also a letter which assists providers appeal overly broad medical records requests by the insurance carrier. These letters make it easy to become a URAC compliance enforcer for your office and your patients.

Access the appeal letters at AppealLettersOnline.com


Helpful URAC Websites

In addition to AppealLettersOnline.com, the following websites contain useful information about assessing insurers for URAC compliance:

URAC Program Overview. This link takes you directly to the URAC page which explains the UR accreditation program and lists the carriers who have agreed to follow the standard.

http://www.urac.org/about_complaint1.asp. Complaints filed with URAC regarding noncompliant members will be investigated by URAC. Although URAC cannot resolve problems related to a health plan's determination of benefits, URAC does have the authority to rescind the accreditation of noncompliant carriers. This leverage may assist you in dealing with noncompliant member organizations.

URAC Utilization Management Standards. This site contains the complete URAC utilization management standards which accredited organizations must follow if they render utilization management decisions. These are industry-wide standards for rendering quality UM decisions.

Visit AppealLettersOnline.com for more information or call 888-399-4925.


Alert: Refund Requests Increasing

Many medical billing offices are reporting an alarming number of refund requests. These requests need to be reviewed very carefully for compliance with state laws which restrict insurance carriers from retroactively denying precertifications. AppealLettersOnline.com provides extensive information regarding this issue due to the confusion over what rights insurance companies have to ask for money back on paid claims.

Visit AppealLettersOnline for resources to respond to refund requests.


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