![]() ![]() The form provided above is just the first page in the appeal form provided by Medical Mutual. You need to make a template appeal letter. So, if time is the leading factor as to why your organization doesn’t send appeal letters for your medical claim denials, what should you do? ![]() I don’t blame them…that’s why these places exist.Īnyway, the point I’m trying to make with all of this is that although getting paid for a claim by an insurance provider helps keep the lights on, it doesn’t take precedence over client time.Īll of this mess leads us to the statistic from earlier that pointed out the average rate of writing off claim denials. And, if these organizations had more time, they would allot it toward their clients. In other words, that statistic proves that facilities don’t have time. No wonder burnout is ravaging the healthcare landscape. You see, the majority of doctors already state that they need at least 50% more time with patients. Once you figure out what kind of prior authorization denial you received, you can use this blog post to help you find the perfect sample appeal letter and receive what’s owed to you.Not only are you at a disadvantage already from a statistical standpoint when it comes to medical claim denials but also from a time perspective as well. To overturn PA denials, it’s more so a matter of understanding the insurance organization’s requirements. I mean, there’s a reason why I mentioned that some medical billers submit claims without PA in the introduction. Luckily, prior authorization denials don’t fall under that category. If you’ve worked within the medical billing space for some time now, you understand that some claim denials are impossible to overturn. Providing as much evidence as possible alongside a formally written appeal letter almost guarantees the insurance organization will have no choice but to compensate you for that denial. Include a screenshot of the date of that notification alongside the date you submitted the claim. Maybe the insurance organization did send you notification of the PA changes it made…but you didn’t receive it until after you submitted the claim. In that case, provide screenshots and/or reports generated by your clearinghouse. It’s possible that the insurance changed its PA requirements while your claim was processing. This is where you write and submit an appeal letter. When this happens, find the section about extenuating circumstances within the provider manual of the insurance that denied your claim. ![]() Since insurances put up another guardrail associated with this type of PA, you’ll likely receive a denial from it at some point. Usually, those “circumstances” exist within the insurance provider manual. Insurance organizations only accept retroactive authorizations if they meet extenuating circumstances. This is a special type of PA where the requests for approval come after the fact. Yes, the screenshot from Healthcare Partners earlier had a section that mentioned “Urgent” prior authorizations. In some healthcare settings, medical professionals don’t have time to wait on an insurance organization.įor example, if a patient is in a hospital setting and needs emergency surgery…the medical staff can’t wait around for the acceptance of their prior authorization request. ![]() You’re going to receive prior authorization denials whether you anticipate them as a part of your claim submission strategy or not. If you don’t do that strategy, it’s worth considering…but explaining its intricacies and benefits goes beyond the scope of this blog post. The way that medical billers view prior authorization denials is that it’s easier to overturn than a denial for missing a timely filing deadline. Sure, doing that strategy 100% guarantees that the submitted claim will come back as a denial. That way the insurance organization receives the claim within its timely filing limit. In fact, the process has gotten so laborious that sometimes it makes more sense to submit a claim without prior authorization to save time. Insurances continue to expand their prior authorization requirements, making the process even more labor some. The solution is simple, right? Figure out a way to make this weekly workload easier by streamlining processes. In 2017, an American Medical Association (AMA) found that healthcare facilities spend two days every week working through prior authorization (PA) requirements on average.īased on the current rate of burnout within healthcare, that’s way too much time spent on dealing with insurance organizations. ![]()
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