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Precertification and ICD-10:  Does Your Organization Have Precertification Precision or Precertification Problems?

Denials are expected to increase 100-200% during the ICD-10 implementation scheduled for October, 2015.

How many ICD-10 denials will be related to precertification problems?  Unfortunately, frequently cited ICD-10 implementation studies have not include any analysis of denial sources.  Therefore, it is important to know your current denial rate for denials related to "lack of preauthorization" and "incorrect preauthorization" to have a baseline comparison. . . . Keep reading this article at AppealLettersOnline.com

AppealLettersOnline.com Featured Letters

We have developed two Preauthorization Appeal Letters designed to address suspected ICD-10 delays and denials. These letters will be added to the AppealLettersOnline.com Appeal Letter database shortly before the ICD-10 implementation deadline.  At this time, they are in development and we welcome your comments regarding the letter content.  Go to the AppealLettersOnline.com Download Library to review these customized preauthorization letters:

• ICD-10 Preauthorization Appeals Guidance - New content!

We have also added the following letters to the Workers Compensations Appeals Letter Topic:

• Mississippi Workers Comp Prompt Pay - New Appeal Letter!

• Mississippi Workers Comp Payment Inquiry - New Appeal Letter!

Access these appeal letters at AppealLettersOnline.com

Frequently Asked Questions Regarding Quality Preauthorization Review

We frequently receive the following questions regarding quality preauthorization review:

Question:  Are payers required provide specialists to review preauthorization's related to specialty care.

Answer:  Yes, most state law and professional review standards do require specialty review of specialty care.

The most widely applicable professional standards for utilization review are published by the Utilization Review Accreditation Commission.  They also extend this protection to precertification requests which involve specialty care but is requested by a general practitioner.  The following frequently-asked-question is from the URAC website on utilization review standards:

Question: What is appropriate specialty-matching and does the standard of care in a community factor in?  If there is an appeal by a specialist for a condition which is generally treated locally by a PCP who would URAC like to see reviewing the appeal?

Answer: When selecting a physician to conduct medical necessity appeal, first choice would be a specialist in the area of concern for the appeal, even if the physician requesting the appeal is not a specialist.   Source: https://www.urac.org/resource-center/standards-interpretations/

Contact Tammy Tipton at t.tipton@appealsolutions.com to schedule a customized denial management webinar for your staff covering denial avoidance and effective appeals.