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| Insurer Fined for Late Denials |
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BlueCross to Pay $125,000 for MD Rules Violations
State insurance regulators announced yesterday a $125,000 fine against CareFirst BlueCross BlueShield, the state's largest health insurer, for not following state laws and regulations in its denial of claims.
While some cases involved failure to pay for legitimate claims, the largest number of errors found were in claims that were denied properly, but not within the 30-day limit set by state law.
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Medical Billing Course |
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| Claim Denials, Appeals & State Law |
Dear Subscriber,
The focus of this issue is on claim denials and appeals. If this is a topic of interest for you, please note that Medical Billing Course.com will soon be adding a course in "Appealing Denied Claims."
Stay tuned to future newletters regarding the release of this course.
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How to Appeal Inappropriate Claim Denials
In 2002, 66 percent of one physician practice's total revenue came from claims originally underpaid or denied by health plans and other third-party payers. This revenue would have gone uncollected had the practice not implemented auditing and appeals strategies. Based on this example, it is estimated that physicians are losing billions of dollars in revenue each year by not appealing inappropriate claim denials.
There are many reasons why physician practices do not appeal denied claims; the most common is that they believe appealing claims will create an increased administrative burden on the practice. However, not appealing denied or partially paid claims can be quite costly to your practice and can often result in decreased revenue. Since introducing claims editing software into their claims processing systems, health plans have generated an increased number of inappropriate claim denials and reductions in payment.
An effective way for your practice to combat these erroneous payment reductions and denials is to be diligent in submitting appeals.
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Knowledge is Payment: State Prompt Pay Laws
Providers need to understand state prompt-payment laws to benefit from them. Because these laws arise at the state, rather than the Federal, level, a provider may be afforded protection for a claim for services provided to one patient but not for a claim for identical services provided to another patient. Accordingly, providers need to familiarize themselves with the varying requirements of the states that may exert oversight of the payers with which they do business to take full advantage of these laws. In this era of overlapping and sometimes contradictory regulations, knowledge of prompt-payment laws can make quicker payment possible.
Click here for a listing of "Prompt Pay" Statutes and Regulations by State.
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Medical Billing Course.com recommends DAQbilling by Antek Healthware as your Billing Service or Medical Practice Billing/Management Software.
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