The Federal claims appeals regulations went into implementation on July 1. Here's an update on this and other medical billing and coding information relating to this change.
If you're not up to speed on the new law and honed your Employee Retirement Income Security Act (ERISA) know how, you could be taking your practice to a 'denial zone'. For the initiated, the Patient Protection and Affordable Care Act (PPACA) adopts existing ERISA claim regulation in total and adds on six to seven new standard requirements too.
The new appeals regs:
The just-in appeals regs will impact all your healthcare billing denials and appeals outside of Medicare and Medicaid; as such your billing department will need to be well-versed with them to get back their deserved payments.
The provider side of the healthcare industry does not focus enough on the new appeals regulation while the payer side of the industry talks about it all the time to ensure you don't get the payments.
Also bear in mind that PPACA is a Federal mandate and as such it's not optional.
Appeals options: Under PPACA, now there are both internal and external appeals options.
The good news is that for the internal appeals process, PPACA adopted ERISA claims regulations in their entirety and added six to seven new requirements as well. The law provides the just-in external appeals option by adoption the National Association of Insurance Commissioners (NAIC) external appeal model.
Note: As the practice or provider, you have no claim with the insurance company.
The appeal rights belong to the patient and not your practice; as such you need to get the patient's written permission to appeal a claim under ERISA. Under Federal Law, a provider or the representative of the provider can appeal an adverse benefit determination minus the written authorization by the member.
Under PPACA, if you have 'good assignment' from the patient, the healthcare provider will become a claimant during the appeals process.
PPACA requires one EOB format for the entire industry
A notable change is that PPACA requires explanation of benefits (EOBs) format for the entire industry. EOBs will be for initial denials called the adverse benefit determination, internal appeals denials (the final internal adverse benefit determination), and for external appeals denials (the final external adverse benefit determination).
Resource: For more information on the Federal claims appeals regulations, you can visit the labor department Website at http://www.dol.gov/ebsa/healthreform/.
If you're not up to speed on the new law and honed your Employee Retirement Income Security Act (ERISA) know how, you could be taking your practice to a 'denial zone'. For the initiated, the Patient Protection and Affordable Care Act (PPACA) adopts existing ERISA claim regulation in total and adds on six to seven new standard requirements too.
The new appeals regs:
The just-in appeals regs will impact all your healthcare billing denials and appeals outside of Medicare and Medicaid; as such your billing department will need to be well-versed with them to get back their deserved payments.
The provider side of the healthcare industry does not focus enough on the new appeals regulation while the payer side of the industry talks about it all the time to ensure you don't get the payments.
Also bear in mind that PPACA is a Federal mandate and as such it's not optional.
Appeals options: Under PPACA, now there are both internal and external appeals options.
The good news is that for the internal appeals process, PPACA adopted ERISA claims regulations in their entirety and added six to seven new requirements as well. The law provides the just-in external appeals option by adoption the National Association of Insurance Commissioners (NAIC) external appeal model.
Note: As the practice or provider, you have no claim with the insurance company.
The appeal rights belong to the patient and not your practice; as such you need to get the patient's written permission to appeal a claim under ERISA. Under Federal Law, a provider or the representative of the provider can appeal an adverse benefit determination minus the written authorization by the member.
Under PPACA, if you have 'good assignment' from the patient, the healthcare provider will become a claimant during the appeals process.
PPACA requires one EOB format for the entire industry
A notable change is that PPACA requires explanation of benefits (EOBs) format for the entire industry. EOBs will be for initial denials called the adverse benefit determination, internal appeals denials (the final internal adverse benefit determination), and for external appeals denials (the final external adverse benefit determination).
Resource: For more information on the Federal claims appeals regulations, you can visit the labor department Website at http://www.dol.gov/ebsa/healthreform/.
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