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RAC, CERT, ZPIC, MAC. These are acronyms that send shudders through most hospital’s C-Suites, given their perpetually increasing aggressiveness of “un-paying” hospitals, and now physicians1. Understanding LCD's and NCD's A majority of these “un-payments” are made on...read more
There is no reason to ever write an appeal letter from scratch. You will never write just one appeal for chest pain or knee replacement surgery. Denials come in multiples. The only difference from the first chest pain denial and the twentieth is the circumstances of...read more
When I teach appeal writing, I like to ask the group this question, “Which knowledge area in appeal writing is the most important? Is it knowledge of the payer, knowledge of the area of medicine concerning the denial, or is it knowledge of the hospital and the...read more
For a new appeal writer, learning the language of health insurance can be daunting, especially if one’s background is clinical and not business oriented. I remember as a newbie reading the CMS regulations on payment policies over and over again. I’d tease out every...read more
The inclusion of evidence based guidelines (EBGs) is imperative in appeal writing involving medical necessity denials, including level of care or medical necessity of a procedure. It’s one of the fundamentals but probably the most important aspect of appeal writing....read more
Every now and then I read about how Medicare has denied payment for certain services due to lack of authentication of medical record entries. That means no physician signature on orders, progress notes, histories and physicals, etc., or the signature is illegible and...read more
What role do screening tools such as Milliman Care Guidelines (MCG) or InterQual® admission criteria play in writing appeals? I'm often asked this question when I’m teaching appeal writing in hospitals. Hospitals are tasked by regulations to follow a utilization...read more