Outpatient Surgery Magazine - Subscribers

Surgical Smoke Nearly Killed Me - Outpatient Surgery Magazine - February 2018

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

Issue link: http://outpatientsurgery.uberflip.com/i/940425

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Page 21 of 128

reviews let you discuss poor quality appeal review components obtained at the lower levels of review. Unfortunately, on the commercial coverage side (group and individ- ual health plans), provider appeals are often limited to 1 or, at best, 2 internal appeals with a payer. However, obtaining an authorization from the patient to pursue external appeal review is often an option that lets you escalate to an external review process with independent decision makers. In an effort to improve what was widely recognized as "ineffective appeal processes," the ACA sought to standardize healthcare insurance appeals for group and individual insurance plans and universally extend access to the gold standard: external/ independent review of denied healthcare claims. Since the ACA passage in 2010, independent review organizations have lined up medical dream-team level reviewers to meet the challenge of reviewing cases. While the scope and role of independent review has grown signifi- cantly since passage of the ACA, few consumers — an estimated 1 in 1,000 — use the process. Getting consumers to file even an initial appeal, much less Level II and External Review requests, remains daunting. Fortunately, the treating medical professional has the right to act on the patient's behalf when you believe an insurer is wrongfully denying access. The provider is often in the best position to pursue the process altogether — records collection, drafting and submis- sion — and may even benefit from the dialogue regarding how plan/policy language addresses coverage questions. To insure that the providers can participate, if willing, the ACA made clear that the patient can assign their right to pursue appeals to any other party: a willing family member, a training advocate or the medical organization that provided the treatment. Unfortunately, med- Coding & Billing CB 2 2 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • F E B R U A R U Y 2 0 1 8

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