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Our experts offer advice, resources and share the pulse of our industry.

Leveraging Limitation on Liability to Win Appeals

Limitation on Liability is a very common phrase to appeal writers, specifically when dealing with government denials. It’s a crucial argument that is vital to a winning appeal argument. Have you ever stopped to think about what that phrase means? Have you ever dug...

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The Triad of the Appeals Team

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...

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Speaking the Same Language as the Payer

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...

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Using Evidence Based Guidelines to Win Appeals

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....

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Physician Signatures Matter

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...

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The Role of Screening Tools in Writing Appeals

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...

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