The Appeal Letter

ISSUE 28 November 11, 2004

	PPO Discount Dispute Ruled Unrelated to ERISA Often, medical providers end up agreeing to larger discounts than they hoped to negotiate. This problem is compounded when the managed care plans you participate with frequently employ unfair denial and delay tactics. However, the managed care contract seems to contain many protections making it hard for medical providers to appeal or litigate poor claim payment performance on the part of the insurance carriers. Read this entire article for a discussion of recent cases beneficial to providers who find themselves contemplating litigation over a managed care breach of contract.
	December Audioconference on Appeals Your last chance this year for getting your staff trained for appeals is coming up December 16. Appeals – When “Limitations and Exclusions Apply” Isn’t Good Enough is a 90-minute audioconference featuring information on asserting your rights when insurers provide canned denials. Tammy Tipton, President of Appeal Solutions, will discuss what laws apply to appeal review and how to use them in your favor to obtain such pertinent details as the credentials of the reviewer and the documentation in the claim file or policy which support the denial. A number of Level II appeal letters will be presented and discussed at length. Appeal Solutions is adding a number of Level II appeals to the AppealLettersOnline.com database to assist members with ensuring that the denial is looked at by different personnel at different levels within the insurance company. Over 95% of past attendees have said that their facility benefited from this audioconference and that they would be implementing several of the techniques and appeal letters presented during the audioconference. The live audio conference will be held Thursday Dec. 16th at 11 a.m. CST. Cost is $197 per dial in line. Purchase one line and train your entire office staff on appeals. The audioconference is also available on CD-Rom. Click here for details... or call 888-399-4925.
	New Feature at AppealLettersOnline.com AppealLettersOnline.com now has a feature to allow users to pull up only letters specific to their state. The “Select Letters By State” option appears on the appeal letter repository page beneath the subcategory selection. Selecting this option allows you to select your state and then view both general appeal letters and state-specific appeal letters for your state......sign up for access to the appeal letter repository
	New Letter to Assist With Payments Not In Compliance With Contractual Terms We have added a new letter to the AppealLettersOnline.com Repository regarding failure to pay according to contractual terms. The letter is located in the Topic “Benefit Reductions” under the “Miscellaneous” Category under the letter title “Payment Not In Compliance With Contract.” The letter assists providers with citing information directly from the contract and also asks the carrier to respond with detailed information regarding what portion of the contract was used to calculate the received payment. The letter also states that since managed care contracts are contracts of adhesion, the organization responsible for drafting the contract wording can be responsible for unclear and ambiguous terms.
	Specialty Highlight: The AppealLettersOnline User forum recently featured a discussion of payment Code G0289, "Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chrondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee." CMS Program Memo A-02-129 addresses hospital outpatient facility documentation requirements for G0289 and states that this is a packaged service under OPPS and that facilities will not receive additional payments for this code. Additional money is paid for the professional fee when G0289 is billed. The memorandum is located at www.cms.hhs.gov/manuals/pm_trans/A02129.pdf and G0289 is addressed on pages 18-19. We invite anyone having experience/advice on reimbursement of this code to add to this discussion.