Blog
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...
Are CMS’ Local Coverage and National Coverage Determinations the Final Word?
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...
Cut your Workload and Win More Appeals with Appeal Letter Templates
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...
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...
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...
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....
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...
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...