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Our Non-Profit Corporate Charter
The
Center shall act as a "Health Insurance Claims Advocate" and "Ombudsmen" to
healthcare providers and privates persons of all socio economic standings, races
and cultures. To bring forward as an advocate and ombudsmen certain identifiable
violations of all health insurance claims settlement laws relating to unfair
practices as practiced by certain health insurance companies throughout the
United States of America.
The Center is dedicated to preserving our community and promoting social welfare
by helping identify violations in health insurance claims settlement laws in
Arizona, California and in all other states within the United States.
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DENIALS
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SPECIAL PROJECTS
An Ounce of Appeal is Worth a Pound of Payment
The health care hue and cry grows louder everyday.
Medical and mainstream publications are filled with stories focusing on the
barriers doctors and hospitals face in getting paid in today's health care
environment. Pre Certification, managed care and tight timely filing deadlines
are just some of the hurdles medical professionals must finesse when seeking
reimbursement. And if one hurdle is missed, the effort and attention expended in
the examining room is all for naught in the business office.
Yet most medical providers ignore what is perhaps the most effective action they
can take for securing immediate payment on a denied medical claim - filing an
appeal.
"Ninety-five percent of the doctors’ offices I have worked
with do not appeal their insurance denials. They do not know how and they do
not have the time, " said Linda Cagle. Cagle is a practice management
consultant in Dallas, Texas and the administrator for Surgical Institute, an
oncology specialty group.
"My motto is to appeal everything. The worst thing they can say is no."
Appeals Worth the Effort
At any given time, Cagle has a stack of explanations of benefits on her desk
with "Appeal" written boldly across the bottom. She recommends that physician
offices spend an hour a week filing appeals. The appeals generated during this
time can easily pay that staff member's salary for the week, she states.
While many carriers do not routinely release the number of claims overturned on
appeal, statistics indicate that a well written appeal may be effective in
securing payment. According to an article printed by The Dallas Morning News,
"Texans File Few Health Care Appeals," the Texas Department of Insurance is
receiving a fraction of the expected number of appeals under a law requiring
carriers to pay for external reconsideration of claim denials. The story quotes
several insurance industry officials who believe appeal numbers are low because
most appeals are favorably resolved through the insurance carrier's appeal
process.
That story states Prudential HealthCare has a two-step internal appeals process
and about 25 percent of treatment denials are overturned during the first phase.
Of those cases appealed a second time, another 20 to 25 percent are overturned.
These statistics makes it easy for Cagle to commit a staff member to one hour
per week of writing appeal letters. And, according to Cagle, she now uses a
software solution which allows her to multiply the number of appeals she files
each week.
"It is imperative that a physician's office doesn't just base their claim's
appeal on billing guidelines but also the regulatory environment that the payor
must exist under. I am now encouraging my staff to know and understand state and
federal insurance laws and regulations," said Layton Lang, Chief Operating
Officer for Southwest Vascular and Surgical Group in Dallas.
Like Cagle, Lang in one of a growing number of medical billing professionals
who, in reaction to recent tightening of healthcare reimbursement requirements,
now appeal as many claims as possible.
"More and more payors are hardening up their claim's processing rules and
definitions for 'clean claims' in order to increase profit margins in the
competitive market. Other plans have been so focused on mergers and growth that
their claims processing departments have suffered with claims adjudications
lags," Lang said.
"Our office has experienced a noticeable increase in improperly processed claims
due to frivolous delays and denials that were not based on coding or improper
filing errors."
Cagle, too, cites a growing number of denials based on clearly unsubstantial
evidence. She said her staff typically appeals an obviously incorrect claims
determination by phone. However, phone appeals sometime take close to an hour
simply due to the amount of time spent on hold. Cagle believes a written appeal
may not only be more effective, but also more efficient and less frustrating to
staff.
Traditionally, medical professionals have expected the patient to pursue appeals
on denied insurance claims. Although some still leave this effort solely to the
patient, many public service groups are encouraging doctors to become more
involved due to the more technical nature of health plans today.
The American Bar Association's Commission on Legal Problems of the Elderly
recently released a report entitled Resolution of Consumer Disputes in Managed
Care. In the report, the commission indicated that many managed care enrollees
need help in navigating the appeal system.
"An enrollee's treating physician is most familiar with his/her conditions and
care needs. Physicians can be natural advocates for necessary and timely medical
treatment. Moreover, physicians have a fiduciary responsibility to patient and
advancing patient treatment or expedited review seems a logical extension of
that role," the report states.
However, without a utility to speed the process, many providers are hard-pressed
to effectively appeal denials.
“All of the medical management systems I have reviewed have possessed limited
ability and space to provide proper tracking and reporting on the disposition of
appealed claims. Power of Appeals is the first system that provides the tools
for accurate claims follow-up and dispute resolution,” Said Lang.
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"If you
aren't appealing denied or underpaid medical claims with the Center for Health Insurance Claims Advocacy,
you aren't really maximizing your practice income". Brandon Maxon
- Vice President, ABA CPM & Medical Supply
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