Resources to Decrease Denied Medical Claims.
Home | Contact Us | Member Benefits | Search | Member Area
 JOIN NOW
Become a member & get immediate access to all of our resources.
 SEARCH


Take a Free Tour
About ALO
 Who Should Join
 Download Samples
 Member Benefits
 Terms & Privacy Policy
 Take a Tour
 Member Comments
Discussion Forum
 MEMBER RESOURCES
 Appeal Letters
 Audio Conferences
 Discussion Forum
 Download Library
 Articles & Case Studies
 State Resources
 My Membership
 Help
 APPEAL TOPICS
 Providers' Rights
 Benefit Disclosure
 Utilization Management
 Medical Necessity
 Incorrect Payments
 Prompt Pay
 Treatment Excl/Limits
 Refund & Recoupments
 Specialty Care
 ERISA
 Medicare
 Contract Negotiation
 Other Topics
Visit our Online Store.
 Forum Topics
• erisa
• Medicare and Multiple Clearinghouses
• INSURANCE CARRIER DENYING AFTER ISSUING PREAUTH.
• BCBS out of network benefits
• Moderate/conscious sedation denials
• Blue Card
• California Fee schedule
• BCBS Out of Network denials for NY
• medical necessity denial CT scans
• INSURANCE COMPANY STATES NO CLAIM ON FILE
• Reimbursement for twin pregnancy
• florida no fault timely filing
• MEDICARE
• cigna
• DRG denial
Home | Explanation of Benefits



Explanation of Benefits (EOB)

State and Federal Law Requires EOB's to Provide Specific Information.

Denied claims are one of the major problems facing today’s health care professionals. Getting a claim paid, and paid in a timely manner, can be a complicated process. The importance of managing claim denials is paramount in addressing cash flow, compliance and licensing and regulatory requirement issues. Implementing an effective denial management program can improve financial performance more efficiently than generating additional revenue or controlling costs. By viewing a denial program as enhancing revenue, providers can significantly improve their financial performance, cash flow and profitability.

AppealLettersOnline.com can assist providers implement an effective denial management program. AppealLettersOnline.com is an interactive resource provided to level the playing field between Insurance Companies and Medical Providers. You will find appeal letters, case studies, articles, other resources and the latest intelligence necessary to help healthcare providers make vital decisions and take strategic actions to address payer denial issues. AppealLettersOnline.com will help health care providers actively develop the processes, analytical tracking information, educational programs and procedures needed for implementing an effective denial management program.

Some of the topics covered at AppealLettersOnline.com include addressing payment reductions such as usual and customary and out-of-network care reductions, lack of timely filing denials, pre-existing conditions and medical necessity appeals and improving verification of benefits procedures. Treatment exclusions, maximum benefits denials and subrogation/coordination denials are also discussed. Tips are also provided on appealing for interest and penalty payment on late payments and appealing a request for a refund of previously paid claims. AppealLettersOnline.com discusses all types of claims including Managed Care, Indemnity, Government, Self-Funded, ERISA claim issues and managed care contractual payment discrepancies.

The Problem:  Insurers call it an Explanation of Benefits.  But many EOB’s read little more than "Claim denied" and leave the explanation to your own guesswork.
The Solution:  A poorly written explanation of benefits may be more than just a nuisance; it may also be a violation of federal and state law. Providers can, and should, attempt to obtain a full explanation for any claim denial.

Both Texas state statutes and ERISA regulations require insurers to include specific information in any denial notice. Insurers bound by state law must state the reason for rejection, according to Vernon’s Annotated Texas Statutes, Title 28, Article 21:55. Further, self-funded plans bound by ERISA must include in any denial notice the reason for denial and include a specific reference to pertinent plan provisions on which the denial is based.

“This can be a direct qoute or a reference to specific portions of the plan,” said Kim Guynan, pensions benefits advisor for the Department of Labor.

“If it is not there, you can certainly request it. The regulations provide the rights to the participant, but the provider can request it. If they do not get a response, then the participant should request it.”
Guynan states that providers are encouraged to request the specifics on health claim denials because many times, claims are denied due to needed medical information. Providers may be able to provide the needed information, such as an operative report or diagnosis code, more quickly than the participant.

Both state and ERISA law also require insurers to indicate if additional material or information is necessary for a review of claim. However, carriers and plan administrators have a wide berth of discretion when assessing whether additional information is needed to reject a claim. Carrier Liability
In Booten v. Lockheed Medical Benefit Plan, a patient sought payment for oral surgery undertaken after four of her teeth were almost knocked out. The treatment plan centered on resetting the teeth by splinting the loose teeth to her back teeth. Aetna paid a portion of the claim but denied any expenses related to the back teeth because they were not injured. Aetna determined that any work to the back teeth was strictly dental and no medical records were requested to determine the relationship of the back teeth to the injury and subsequent treatment.

The patient’s doctor’s submitted medical information explaining the procedure. However, Aetna responded with a serious of letters which stated simply, “These services are not covered under your Lockheed Medical Benefits Plan.”

After ruling in the patient’s favor, the court noted that Aetna could have easily obtained the medical rationale from providers that these services were the result of an accident. But instead of requesting these records, Aetna issued what the court regarded as “a stream of cookie-cutter denial letters.”

“What we got here,” the court records state, “is a failure to communicate. This is an all-too-common occurrence when ERISA-covered health benefit plans deny claims. While a health plan administrator may - indeed must - deny benefits that are not covered by the plan, it must couch its rulings in terms that are responsive and intelligible to the ordinary reader. If the plan is unable to make a rational decision on the basis of the materials submitted by the claimant, it must explain what else it needs.”

Seek Patient Involvement

Guynan said that ERISA specifically mandates carriers must indicate if any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary. However, once again, the law is written so that the participant has a right to this informaton.

If a provider is having difficulty getting information from the carrier, Guynan said that a conference call may be helpful in resolving the issues. That way all potential parties are there to contribute information. Finally, to comply with state and ERISA regulations, denials must contain information on appealing the decision. If any of the required information is not in the EOB, providers should seek it and ask for the response in writing.

AppealLettersOnline.com can assist providers implement an effective denial management program.

AppealLettersOnline.com is an interactive resource provided to level the playing field between Insurance Companies and Medical Providers. You will find appeal letters, case studies, articles, other resources and the latest intelligence necessary to help healthcare providers make vital decisions and take strategic actions to address payer denial issues. AppealLettersOnline.com will help health care providers actively develop the processes, analytical tracking information, educational programs and procedures needed for implementing an effective denial management program.

Some of the topics covered at AppealLettersOnline.com include addressing payment reductions such as usual and customary and out-of-network care reductions, lack of timely filing denials, pre-existing conditions and medical necessity appeals and improving verification of benefits procedures. Treatment exclusions, maximum benefits denials and subrogation/coordination denials are also discussed. Tips are also provided on appealing for interest and penalty payment on late payments and appealing a request for a refund of previously paid claims. AppealLettersOnline.com discusses all types of claims including Managed Care, Indemnity, Government, Self-Funded, ERISA claim issues and managed care contractual payment discrepancies.




Take a quick tour >>

Download sample letters >>

Join now for less than $1 per day >>

 MEMBER LOGIN
Username:
Password:


 
Sign in Problems?
 SAMPLE LETTERS

Download FREE
Sample Appeal Letters

E-mail:

 TESTIMONIALS
"The service more than paid off. The first one I used had a yield of $19,700. It was a preauthorization issue. I used one of the appeal letters I purchased as the framework for the appeal I constructed. I have won quite a few utilizing the letters this way. They are a wonderful resource."

Mary W.


"My facility has been utilizing your service for almost two months. We are actually realizing payments on Managed Care denials that we would have otherwise written off. Also, for the first time, instead of us hunting the insurance companies for payment, the insurance companies are reaching out to contact us after receiving our letters. It's amazing the turnaround!"

Sheryl M.


"I just want to say that this is the greatest reference to appeal letters that there can be!"

Agnes S.


"The content of the appeal letters really provides results, both in overturned claims and prompt responses from carriers. Some letters work better than others, depending on the denial reason, but they give us the means to appeal any type of denial and exercise our right to have denials reviewed and to be provided with proof to support their position."

Peggy A.


"In today's payer environment, we need to be armed with the most powerful weapon to look out for the rights of our doctors and get them reimbursed fairly for the work they have done. Appeal Solutions gives us that ammunition."

Barbara C.


"I attended a Coding/Reimbursement seminar this past weekend in Las Vegas. During the conference I announced to the crowd that your service has saved us labor and precious revenue. I just wanted you to know that you have an effective service and our office has enjoyed the ease and rate of success we have enjoyed since we began using it."

Melissa G.


"I am a subscriber to your website and I absolutely love it."

Theresa D.


"I purchased the membership and wanted to tell you that I used one of the letters as suggested by you and was able to get the denial overturned. It was worth about $12,000."

Jolyn T.


"I never got a chance to let you know how much the letters helped me in collections. I was able to collect $98,000.00 on JUST ONE clinical trials case from an HMO case because of the ground work your company did. Your letters really do work. Such a great service and a great assistance to the patients who do not know the ins and outs of the Insurance juggernaut. INVALUABLE TO SAY THE LEAST!"

Terri P.


"Your website has been very helpful! Worth twice the price!"

Maria T.


"I just purchased your service and only being on it the very first time and in only 20 minutes, it is blowing my mind with all the information and tools you offer. I have racked my brain in some instances with these carriers and how to play their games. I have appealed, re-appealed, and even gotten suggestions from others on appeals. Your letters are law guided and I know will be more beneficial to us at work. I can't wait to share this new found information. I only purchased your product for one year as a trial basis in tracking increased reimbursement by using your letters; but I feel I will be extending this and/or upgrading before the year is out. Thank you so very much, and I am glad I was surfing today. I was at the end of my rope."

Debra M.