TOUR: Appeal Topics
Appeal Topics cover the ABCs of successful claim recovery and denial avoidance. Our goal is to provide effective appeals as well as explain in detail what steps to take to avoid denials and improve processes.
Each topic page breaks the topic into crucial concepts, proven recovery strategies and sound denial avoidance ideas. Numerous suggestions address payer noncompliance and developing Level II and Level III appeals on those appeals which do not result in high quality appeal responses. Links take you to handy references to further supplement your arsenal of information.
Medical providers who file appeals on behalf of patients provide a valuable service by resolving complex issues that patients are not in a position to effectively resolve. . . .more >>
Seeking a verification of benefits is an important activity in today’s healthcare reimbursement process. However, not all verifications are equal. Learn how to improve the quality of the benefits information you obtain and incorporate verification of benefits confirmation into subsequent appeals. . . .more >>
A preapproved claim usually results in claim payment. Therefore, it is imperative that medical professionals demand a quality utilization review decision each time prior approval is sought. Appeal Solutions has extensive information on initiating appeal during utilization review. . . .more >>
Medical necessity appeals shape healthcare. Uncontested medical necessity denials result in a subtle shift in treatment availability to the next patient because insurance carriers aim to consistently apply medical necessity limitations. Effective medical necessity appeals, on the other hand, bring to the carrier’s attention necessary variations in care, emerging efficacy issues, and situations that reveal flaws in the day-to-day clinical application of the carrier’s written criteria. . . .more >>
Incorrect Payments & Reductions
Insurance carriers now exercise great control over both in- and out-of-network payment through implementing fee schedules, usual, customary, and reasonable (UCR) limitations, and, more insidiously, computerized payment methodologies for applying internal bundling, downcoding, and other price control features. . . .more >>
State specific prompt payment laws can be cited on stalled and pended claims. Learn all about prompt payment laws and state variations on the protections which apply to medical bills. . . .more >>
Treatment Exclusions & Limitations
Treatment Exclusions and Limitations have a direct impact on provider reimbursement. Unfortunately, denials related to policy or plan exclusions and limitations are often not appealed because providers do not have sufficient information regarding the policy or plan terms. Learn how to approach these types of appeals. . . .more >>
Refund & Recoupments
Many overpayments, such as duplicate payments or clearly erroneous payment amounts, are often easy to detect due to credit balances. More problematic, however, are refund requests received which request reimbursement for claims that appear to have been paid correctly by the carrier. . . .more >>
We have a number of specialty-specific medical appeal letters to assist our specialty care clients with appeals related to their specific practice areas. These letters focus on demanding peer-to-peer reviews and release of clinical review criteria applicable to specialty care. . . .more >>
The Employee Retirement Income Security Act of 1974, also known as ERISA, is a federal law applicable to most employee benefit plans, excluding state and federal employees and religious organizations. The Department of Labor estimates. . . .more >>
Medicare appeal changes were implemented in 2005 that expanded providers’ rights and guaranteed prompt responses to appeals as well as qualified, independent reviews at upper-level appeals. Limitations have been added, however, that apply to. . . .more >>
Healthcare billing personnel often begin to view the provider–carrier relationship as an adversarial, often dysfunctional partnership, and improving that relationship may be low on a long priority list of urgent action items. However, the development of a mutually beneficial working relationship that fosters problem-solving can be. . . .more >>
Download Sample Letters.
Return to Tour.