In Billing
Dec 19th, 2016
Provider agreements (or the ancillary documents) outline the formal processes to appeal payers’ payment decisions. You must review your agreement (or ancillary documents) with the specific payer to comply with the rules of the appeal process. A meritorious appeal may fail because you didn’t meet deadlines, follow the outlined procedures, or provide the necessary information. ...
Part 3: Learn how to appeal appropriately. By  Dennis Mihale, MD, MBA; Jeremy P. Burnette, JD, MA; and Sidney Summers Welch, JD, MPH Being audited is serious business. If you think there is an error with the payer’s findings, you have a right to appeal the decision and should do so, as appropriate. But you’ll need to ...
In Audit
Sep 12th, 2012
A recent appeals court ruling upholds Medicare regulations that give recovery auditors the right to reopen claims paid one to four years previous. Auditors need only good cause to reopen such claims and, per Medicare regulations, a good-cause determination cannot be challenged, the court said. The implications of this ruling have industry experts worried. Any ...
Jun 1st, 2012
Let under-utilized appeals systems work for your practice. By Heather M. Shand, CMAA, CBCS, CMB Sometimes, even if you do everything right, you may end up with denied claims. Rather than throw up your hands and walk away, you should appeal. Yes, it will mean extra work, but the results are worth it: Most of ...
Nov 1st, 2011
Question Here is an excerpt from the Medicare Program Integrity Manual, Pub. 100-08, chapter 3, section 3.3.2.5, which addresses Late Entries in the Medical Documentation:“This section applies MACs, CERT, Recovery Auditors, and ZPICs, as indicated.A provider may discover that certain documents were misfiled or needed to be filed in the medical documentation during the process ...