7 Steps to Getting Experimental Surgery Authorized

Do you need experimental surgery or this is what your insurance company called it. Is it really experimental surgery? How many times has it been performed? Who performed it? Before you hear from your medical insurance the procedure your doctor wants to perform is considered experimental, too expensive, the statistics are low for the surgery to be beneficial. Think again.

 Your medical insurance said they will not pay for the surgery what is your next step?

Calm down think logically. You need to appeal!! You need this surgery to save your life or limb.

These are the questions you need to ask yourself?

1. Is this the surgical procedure I really need?

2. Is there another surgery which is better?

3. Is the surgeon that really can perform this particular surgery on your medical plan or is the surgeon out of network?

4. What will be the entire cost of the surgery?

5. HOW DO I GET MY MEDICAL INSURANCE TO PAY FOR THE SURGICAL PROCEDURE?

BREAK DOWN OF CHARGES:

a. Charge of operating room?

b. Charge for surgeon?

c. Charge for assistant surgeon?

d. Charge for anesthesiologist?

e. Charge for Laboratory?

f. Charge for X-rays?

g. Charge for unknown?

1. You can get this information simply by calling your doctor's office. There will be somebody whose job it is to get this information to you.

With this information in hand you will now have a substantial plan in hand.

2. Another vital part of your appeal is getting the names of people who have had this experimental procedure performed and your insurance company has paid for it. You will need a list of their names, date of surgery, the name of surgeon, the surgical procedure performed.

You can get this information by requesting it online at any of the popular websites. Make sure you include in your request why you need this information. Include your contact information (name and email address)

This is the time to think outside of the box to get all the information you need, what phone calls to make, and what websites can get you the information you need.

3. If the surgeon you want actually performs this particular surgical procedure, is on another medical plan, you must get this same estimate from that physician's office.

You can then do a cost comparison.

In an appeal letter in  which the surgical procedure you need has been denied, ask the insurance company what form of MEDICAL NECESSITY information they need.

4. What is in your contract about this type of appeal procedure?

You can get some of this information off the internet in your medical insurance company's website. If you can't get everything you need call and ask them to mail it. Make sure whatever you receive you send back to them in the appeal package.

5. Always send medical records with your appeal. You can request them in writing from your physicians, hospital, x-ray, lab, ambulance, etc.

6.. Fax your appeal letter and all your documents the more documents the better make it at least 20 plus pages.

Get to the top person in your medical insurance company.

Do your homework.

Use your computer or start calling and asking for the CEO's phone number, fax number and email #.

The president, vice presidents any body in power.

Then fax all this information marked Urgent Expedite Immediately and I would add Personal and Confidential.

Fax this at midnight on Sunday night.

Fax it to everybody you can get their fax #s.

Make sure you change the Fax information sheet.

The name of the person being faxed, title, your name, Appeal Letter for Specific Surgery

CPT and ICD numbers. CPT numbers is the reason for the visit Example: Doctors Visit, ICD is the medical diagnosis Example: Ear infection.

How many pages and your contact information which includes not only your name, phone number, email address, your insurance identification number.

I would also Email it all at the same time to each person. Do not forget anybody.

This is a life or death situation and you can put this appeal letter together with the guide lines above.

Remember money talks and if you can prove the surgeon you want (not the one the insurance company will give you) will be paid at the same rate, you have a great chance of getting your appeal paid.

Everything is negotiable in medical insurance. If this surgeon or hospital or both are out of net-work the payment can be negotiated by the insurance companies.

Experimental Surgery Authorized What About the Doctor

The experimental surgical procedure has been approved. Yeah!

Now is your battle really over? If this is experimental surgery there are not many doctor's which will do this very new surgical procedure.

Now is the time for you to do your homework. What is the name of the doctor  who does this particular surgical procedure? How do I get this doctor to do the procedure for me and get my insurance company to pay for it, even if it is out- of-network.

Now you need to write another appeal letter.

You do a cost comparison between the doctor your insurance company picked and the doctor you want to perform your surgical procedure. See above.

You can get statements in writing (if possible) from physicians who are picked to perform this experimental procedure to say they do not do this kind of procedure they work in another part of the body. They make charge you.

The important thing is get your surgical procedure authorized, get the right physician and have a great life. Thank you for reading my article. Please feel free to read any of my various articles on numerous subjects. Linda E. Meckler copyright

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A Dozen Steps to Successfully Appeal Denied Claims

Appealing denied claims used to be a simple process. A biller working with a physician's office would stamp "APPEAL" in big red letters on a photocopy of the claim, and mail it back to the insurance company. These days, you'd be wise to put the cost of that postage in the bank, and throw away both the APPEAL stamp and its red ink stamp pad. This sort of knee-jerk response won't even make it past the insurance company's initial computer screening; they'll likely toss such "appeals" into the trash and you'll never hear anything back from them.

To successfully appeal denied claims, you need to get your "A-game" on; otherwise, you won't see a penny for your efforts.

Follow these steps to effectively appeal denied claims.

1. Recognize denials. Insurance companies don't print the word "denied" in big letters across the top of the claim form. In fact, the word "denied" may never appear at all. The insurance company simply declares the reimbursement amount to be "$0" and enters an adjustment reason code next to the amount paid. The key is to identify it as separate and distinct from a contractual adjustment, which is - and should be - a write off.

2. Understand why the claim was denied. Before you pick up the phone and demand to speak to the claims representative, determine the root cause of the denial. You can't effectively appeal until you know why payment for the service was denied. In addition to the reason code, there is a remark code. Look up the insurance company's definition of that code to get details about the reason for the denial. WPC maintains a complete listing of standard reason and remark codes, available on their website.

3. Don't procrastinate. There is often a timeframe in which you can resubmit a claim after it's been denied. Pull the record, research the code, call the patient, etc., but don't delay: most insurers only allow a few months to resubmit a claim for reconsideration.

4. Follow the insurance company's rules. Each insurer has an appeal process. The Centers for Medicare and Medicaid Services (CMS), for example, has a form to complete when appealing the denial of a Medicare claim called the "Medicare Redetermination Request Form". Get familiar with the insurer's protocols to understand your options if your first appeal is turned down. Don't give up; most insurers have multiple levels of appeals and even a grievance process if you disagree with the outcome after you've exhausted the appeals process.

5. Make a compelling case. An appeal means that you disagree with the insurance company's decision, so put your debate cap on and gather supportive evidence to present your case. Perhaps the most important aspect of your claims letter is the content. The letter should go well beyond stating, "please pay my doctor." Build a compelling case for why the claim should be paid:

Develop a professional letter that begins by referencing the claim number, date of service and patient; then, briefly describe the particulars of the service in question. Use the insurer's own language if possible. For example, to appeal a claim denied because the insurance company claims the treatment was experimental, quote from the insurer's own marketing materials where it declares it seeks to provide the best medical care for its beneficiaries. When the insurer questions the necessity or separate payment for a distinct service, the physician should type or dictate a paragraph or two about the benefits of the service to the patient. Seek objective evidence to support your case from your specialty society and medical literature. Look to see if Medicare or Medicaid pays for the service; if they do, you can argue that even the government has determined that payment is appropriate. Copy and attach sections that support your case from coding manuals, including past issues of the American Medical Association (AMA) CPT Coding Assistant, a periodical that the AMA publishes to clarify CPT codes. For appeals that concern clinical issues (for example, medical necessity), send the appeal to the medical director of the insurance company. Look at the class action settlements between several large physician organizations and a number of national insurance companies; review those settlements to see if anything in there can support your position. See the HMO Settlements site for up-to-date compilation of the settlements, as well as a list of pending lawsuits.

6. Confirm receipt. Don't just send the appeal and hope for the best. Review your submission online, or call the insurance company to confirm that they received your appeal, noting the name of the operator, extension number, date and time. Place a tickler in your practice management system or Microsoft Outlook to follow up in 30 days.

7. Set boundaries. Although it might make you feel better to fight for every dollar, it doesn't pay to prepare a third-level appeal of a $2.41 service, particularly if you only perform it once a year. Establish protocols for dollar thresholds that you'll appeal only once, twice, etc.

8. Don't go overboard. Avoid fighting for a claim that should have never been submitted in the first place, such as an undocumented service. Your physician may have provided the service and feels there should be some way to get paid, but - as the saying goes - if it wasn't documented, it wasn't done.

9. Carbon copy stakeholders. Your appeal to reverse a denial is a matter between you and the insurance company, but sometimes pulling in other key stakeholders helps. Your first, and most important, advocate is the patient. Although patients may never be held responsible for payment if a denial is ultimately upheld, news of payment disputes certainly get their attention. And the patient's attention is just want you want. Prompting the patient to contact the insurance company directly to encourage payment doesn't guarantee payment, but it certainly helps.

10. Develop supportive language in your contract. Your contract establishes the relationship between you and the insurance company. Even though the insurer is the party that typically presents the contract to physicians for their signature, it's every bit as much your physician's contract as it is the insurer's. Proactively negotiate the inclusion of language that supports your efforts to appeal claims. If you're frustrated by the appeals process itself or if you keep running into certain problems, such as unfair bundling denials, seek to include clearer definitions of these processes in the contract.

11. Compile appeals. Appealing claims one-by-one may get the results you need, but it is laborious. If you've seen the same service denied for the same reason multiple times - or your insurer hasn't paid in a timely manner, according to your state's prompt payment law - compile your appeals and present them together for reconsideration.

12. Maintain a hassle folder for each insurance company. Keep a record of denied claims - by dollar and type. Measure and compare the data on a quarterly basis. If you negotiated a good reimbursement rate with an insurer, but all of your claims get denied, the "good" rate is meaningless. It pays to maintain a record of reimbursements and denials in order to effectively review your contract for its strategic contribution to the practice's bottom line.

Preventing denied claims is a key skill of successful billers. But getting some denials will always be a fact of life in today's complicated physician payment system. Appealing denials is your right: it pays to exercise it.

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