The Appeal Letter

ISSUE 38 September 19, 2006

	U.S. District Court of Appeals Finds BCBS Direct Payment to Patients Violates Assignment of Benefits Law The Blue Cross Blue Shield practice of mailing direct payment of out-of-network benefits to patients instead of assignment-holding providers was recently found to be a violation of Louisiana law, a ruling which casts into question the legality of millions of dollars in benefit payments which BCBS has sent directly to patients....read this entire article
	AppealLettersOnline Featured Letters: AppealLettersOnline.com has letters citing both the Louisiana and Texas Assignment of Benefits statutes referenced in the above article. Both of these letters have been updated to cite the U.S. Court of Appeals decision regarding lack of ERISA preemption and would be useful to assignment-holding providers in these states who are appealing for a carrier to honor as assignment of benefits for out-of-network care. Several new appeal letters have been added to the AppealLettersOnline.com online database and several existing letters have been changed to reflect updated state statutes. Sign up at AppealLettersOnline.com to access these appeal letters.
	Using Texas Laws to Appeal Denials and Demand Quality Appeal Reviews This audioconference will be presented Oct. 19th and 26th and will feature information on asserting your appeals rights and 20 letters citing Texas utilization review and insurance claim processing regulations. 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. There are a limited number of slots available for this audio conference - call 888-399-4925 to reserve your spot today, or visit www.appealsolutions.com for more details or to register online.
	Solicitation of Comments on Filing Appeals With Medicare Qualified Independent Contractors Qualified Independent Contractors (QICs) are now providing independent review of Medicare denials and Appeal Solutions is seeking information from medical providers who have sent appeals through the new appeal process. First Coast Service Options, Maximus and Q²Administrators are now processing Reconsideration requests involving fee-for-service Medicare denials. See the CMS Fact Sheet for complete information about fee-for-service appeal process changes. We are seeking comments from medical providers who have filed a Reconsideration Request with a QIC. Information being collected includes type of denials submitted, turn around time on the part of the QIC and final disposition of the Reconsideration Request. A conference call will be held on Sept. 28 to discuss the information collected and to exchange information regarding using the new appeal process most effectively. There is no fee for participation. However, completion of a pre-conference questionnaire is required. Please download the QIC Survey Questionnaire and return the completed survey to t.tipton@appealsolutions.com to register for the audioconference. A very limited number of spots are available so interested parties are encouraged to send information by Sept. 23. During the conference call, survey results will be presented and an open forum discussion will follow to allow participants to ask questions and respond with information regarding the Medicare QIC appeal process. QICs were established by CMS to provide appeal review of medical necessity denials by a panel of "physicians or other appropriate health care professionals." The panel must also include professionals qualified to assess the regulatory aspects of the claim. Call 888-399-4925 for more information.