APPEALS
Aurora Medical Billing, LLC (AMB) takes an active approach to the claims management revenue cycle. When a physician's practice assumes that thereimbursement it receives from health insurers is always accurate, your practice may lose revenue. Even when your practice codes claims correctly, health insurance companies may still inappropriately deny, delay, or significantly reduce payments. AMB implements a claim auditing process, which ensures that carriers pay your practice appropriately for your procedures and services. We recently collected over $15,000.00 over a three month period (as of 03/17/2010) for one of our clients utilizing our appeals process. While reviewing payment trends for carriers, we realized that we are actually collecting more with appeals vs. just filing the original claim.
First, we ensure proper payment by streamlining our claims management revenue cycle, or our work flow, to include the proper steps we take to prepare, submit, and collect on your claims, in other words, making sure that we submit every claim correctly.
Second, we streamline our claims audit and appeals process – that is, our internal controls that detect health insurer payment errors on submitted claims and perform appropriate collection efforts to ensure that the carrier processes, adjudicates and pays the claim accurately.
Finally, our clients are entitled to payments for the procedures and services they provide when they have coded and documented their procedures or services appropriately. Therefore, AMB brings all inappropriate denials of claims to the health insurer’s attention through our claims appeal process.
A short overview.
In today’s challenging economy, our client’s practices struggle to maintain financial viability. Health insurance premiums are rising as physician reimbursements are declining, resulting in thin profit margins for many of our clients. Collecting health insurer reimbursement and ensuring the amount collected is correct is not easy, but it is critical to our clients practice’s financial soundness. Our staff consists of individuals who are educated and experienced in coding and billing practices. With our experience, your practice can achieve financial success with our well-trained and educated staff that has a well implemented, effective claims auditing and appeals process to ensure appropriate payment for your practice. The reasons practices do not appeal denied claims are many; among the most common is a belief that appealing claims can be quite costly and result in decreased revenue for our clients. We believe that an effective way to combat erroneous payment reductions and denials is to diligently submit appeals.
Claims appeals are a critical component to your practice.
Many practices lose revenue daily due to partially paid, delayed and denied claims that a physician’s office does not challenge or even notice. Our effective claims auditing and appeals process may significantly increase your practice’s potential for financial soundness. When we appeal inappropriate claims, we send carriers a clear message that your practice will not tolerate inappropriately denied, delayed, or partial paid claims. Our efforts demonstrate that we are committed to pursuing every avenue to collect proper reimbursement for your services.
What does your practice lose by not appealing.
Carriers save money when they partially pay, delay or deny your claim payment because only a small percentage of our clients pursue and appeal routinely. A practice’s lack of auditing and appealing carriers inappropriately paid or denied claim, results not only in a loss of revenue but also the opportunity to recover expenses.
Steps of our appeals process.
1. We appoint a dedicated individual who processes your appeals.
2. We acquire recommended health insurer auditing resources.
3. We run a monthly collection reports on your account.
4. We review every EOB/RA on each claim on the collection report.
5. We then identify the carrier’s basis for the denied, delayed or partially
paid claim.
6. We gather supporting documentation to corroborate reversal of the
health insurer’s determination through the claims appeals processes.
7. We then develop a claim appeal letter and resubmit the claim to the
carrier.
8. Maintain a health insurer follow-up log.
9. Hold claims processing and review meetings with your staff.
10. Continue to appeal inappropriately denied, delayed or partially paid
claims.
In conclusion.
Appeal letters require forceful language regarding carrier appeal review and response requirements. Obtaining a customized, detailed response from the insurance company begins with making appeal letters more specific in regards to the appeal review and response requirements. AMB utilizes hundreds of letters that cite legal requirements regarding appeal processing. Many of our letters cite state and federal claim processing guidelines, which demand that specific information be contained in adverse determinations thus immediately improving both our success at overturning denials and securing more detailed responses for our appeals reviewer.
Partial subject list of our appeals letters.
Assistant Surgeon Denials
Benefit Disclosure Misquoted Benefits
Bundling of Casting Supplies
Bundling-Recoding Reductions
Cardiology Peer Review
Chiropractic Scope of Practice
Cholecystitis
COBRA
Contractual Reductions
Coverage Rescission
Demanding Benefit Clarification Disclosure
Demanding Disclosure of Fee Schedule
ERISA Case Law
ERISA Medical Necessity Decision
ERISA Prompt Pay
Federal Case Law
Gastric Bypass
Global Services Reduction
Implant Devices
Incorrect Payment Appeals
Level Difficulty Modifiers
Manual Manipulation
Medical Necessity (Three Components)
Medical Records
Medicare Fee-For-Service Reconsideration Deadline
Medicare Medical Necessity Definition
Medicare Quality Review Requirements
Mental-Nervous Disorder
Modifier -25
Multiple Procedure Reductions
Neurology Peer Review of Headache
Notice of Original File Date
Obesity
Payment Not in Compliance with CCI Edits
Payment Not in Compliance with Contract
Physician Assistant Scope of Practice
Preexisting Conditions**
Protecting Your Verification Efforts
Provider’s Right To Access A Quality Appeal Process
Provider’s Right to appeal and/or Act as Authorized Representative
Provider’s Right to Litigate
Provider’s Right to Pursue Appeal Without Reprisal From Carrier
Requests for Peer Review
Request for Clinical Criteria
Request for COB-SOB Clause
Request for Coding Credentials
Request for Coding Criteria
Requests for Peer Review
Request for Proof to Support Refund
Request for Retroactive Precert-Authorization
Request for Reviewer’s Credentials
Silent PPO
State Prompt Payment Laws
State of Texas Law, Texas Insurance Code
Texas Participating/Non-Participating Payment
Treatment Exclusions/Limitations
US Mental Parity Act
UCR Reduction Based on Medicare Allowance
UM22-23 Peer to Peer Conversation
UM24-26 Lack of Timely Decision
UM41 Lack of Appeal Response
Untimely Request for Refund
Usual and Customary Reductions
Verification of Benefits
**soon no longer a necessity under President Obama's new healthcare law.
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