Jan 8, 2015

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Physician Role in Patient Advocacy: Getting to YES During Pier Review

Physicians often lament the days of yore when treatment decisions were made in the exam room and not the insurance company board room. However, a healthcare consultant who specializes in assisting healthcare organization secure coverage for new medical technology says physicians still have a say in individual coverage decisions.

Mary Corkins, Founder of The Reimbursement Group, assists healthcare organizations navigate the ins and outs of securing coverage for technology biologics and medical devices. She consults on the range of challenges new medical products face, from launch to collections and one of the unique services she provides is telephone support during physician peer reviews involving coverage decisions.

Peer-to-Peer conferences, Corkins acknowledges, are "avoided like the plague" for a number of compelling reasons. Historically, peer-to-peer was not an across-the-board protection and not widely available for many denials. Further, companies that did provide peer-to-peer conference . . . . Keep reading this article at AppealLettersOnline.com

AppealLettersOnline.com Featured Letters

We have letters which cite the URAC standards related to appeal review and peer coversation. The URAC appeal letters are under the collection under Topic: Medical Necessity, Subtopic: Case Management Standards. These letters can be used to request peer conversation or to contest a poor quality peer conversation process:

Appeals Consideration
Lack of Appeal Response
Lack of One Day Response
Lack of Timely Decision
Lack of Written Decision
Peer-to-peer Conversation
Records Request Response
Reversal of Certification Determinations

Be sure and review the letters under Topic: Medical Necessity, Subtopic: State Medical Necessity Terms for additional state regulations applicable to peer review.

Access these appeal letters at AppealLettersOnline.com

Denial Management: Get Your Practice Ready for ICD-10 With Our ICD-10 Claims Resubmission Guide

Claim errors are expected to arise as a result of the challenges in ICD-10 implementation. Your ICD-10 planning should include a review of your incorrect claim identification and resolution process. Make sure that once a claim is identified as incorrectly submitted, it is reworked promptly in order to comply with timely filing guidelines. Make sure that all billers understand that corrected claims must still be timely filed per the payer's filing requirements.

As you assess your incorrect claim identification and resolution process, consider your organization's corrected claim follow-up process. Corrected claims should be reviewed within a short time to determine if the problematic claims were correctly processed as a result of the correction. If no processing has occurred, you may want to initiate a written inquiry via electronic inquiry or a more formal appeal, depending on both the payer and the expected outcome. To assist with this corrected claim follow-up process, download and review our ICD-10 Claim Resubmission Guide and Appeal Letters now available in the AppealLettersOnline.com Download Library.

Contact Tammy Tipton at t.tipton@appealsolutions.com if your chapter is looking for denial management material specifically designed to empower providers to protect reimbursement during the ICD-10 implementation. Tipton can provide customized denial management assistance for your organization's needs and work with your ICD-10 implementation team to improve denial management in conjunction with ICD-10 implementation.


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