The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that, in part, enables beneficiaries to appeal any covered insurance claim to request payment in full. Sounds simple, but it’s not. ERISA is a complex set of laws, and one article definitely won’t provide a definitive process to follow. ...
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Many times, payers deny specific patient treatments, drugs, or hospital stays due to the specific treatment or drug being considered non-covered or experimental. While these claim denials can be argued in a formal appeal on the back end, a health system can also obtain a predetermination for these treatments and drugs ...
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Beginning July 1, 2021, United Healthcare (“UHC”) will begin reviewing Medicare Advantage and commercial claims for sepsis-related treatment on a pre-payment basis and post-payment basis. Previously, UHC only reviewed sepsis-related claims on a post-payment basis. Payer policy changes, such as this, can have a lasting ...
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The Accounts Receivable numbers on most hospital balance sheets are inflated. To give your organization’s finance executives accurate revenue expectations, you must ensure that your receivable is as accurate as possible. Here are three areas where revenue cycle professionals can upgrade their procedures to maximize ...
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Near the end of 2020, New Jersey Governor Phil Murphy signed Senate Bill 2380 into law, establishing that essential workers’ contraction of COVID-19 during the Public Health Emergency is considered work-related and fully compensable for the purposes of workers’ compensation. This law applies to any individuals who ...
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In an effort to improve the patient experience, the healthcare industry is implementing new regulations and expectations regarding price transparency. As part of the new requirements, the Centers for Medicare and Medicaid Services’ (CMS) Price Transparency Final Rule will require hospitals operating in the U.S. to ...
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Thanks to the recent Georgia Supreme Court ruling in Bowden v. The Medical Center (TMC), Georgia hospitals are free from the fear that filing a hospital lien at their chargemaster rates will result in a claim against them for fraud and negligent misrepresentation by a class or an individual uninsured patient. The ...
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When dealing with motor vehicle accident (MVA) claims, the collection rate on third-party liability can be substantially higher than any other payment source—particularly involving patients who have no form of health insurance. Whether managed in-house or outsourced, third-party liability (TPL) programs often generate ...
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Since the global outbreak of the novel coronavirus, many health systems have seen a decline in normal patient services, leaving gaps in revenue. In light of the national public health emergency, Congress has passed legislation designed to support both citizens and hospitals during the pandemic—but without a thorough ...
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In a recently released Care Decision Insights, Humana announced that 145 formerly inpatient-only procedures are now approved at the outpatient level of care. According to Humana, the Centers for Medicare and Medicaid Services (CMS) says that its current inpatient-only list applies to traditional Medicare–but not ...
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