Have You Been Haunted By Medical Necessity Denials?

October 25, 2022 8:31 am | Published by

One of the biggest pains we face is medical necessity denials. Despite sending proper notifications and requesting authorization on time, plans still find a way to deny admission. How do we combat these issues and ensure that providers are reimbursed for services they rendered?

Under 42 CFR 422.113 (c)(2):

MA organization financial responsibility. The MA organization –

(iii) Is financially responsible for post-stabilization care services obtained within or outside the MA organization that are not pre-approved by a plan provider or other MA organization representative, but administered to maintain, improve, or resolve the enrollee’s stabilized condition if –

(A) The MA organization does not respond to a request for pre-approval within 1 hour;

(B) The MA organization cannot be contacted; or

(C) The MA organization representative and the treating physician cannot reach an agreement concerning the enrollee’s care and a plan physician is not available for consultation. In this situation, the MA organization must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with care of the patient until a plan physician is reached or one of the criteria in ยง 422.113(c)(3) is met.

RevAssurance Online is currently being used in 35 different states to help providers advocate for medically appropriate healthcare and increase authorization and revenue capture!

Our online platform gives you the ability to access the powerful reimbursement tools used by the claims compliance experts of ERN/The Reimbursement Advocacy Firm. This robust training program is for new and existing employees to access administrative laws that enforce reimbursement and combats improper denials.

RevAssurance Online has many wonderful benefits such as:

  • Resources to MA, ERISA, VA, HMO, PPO plans
  • Denial Topics Encyclopedia
  • The New Appeal Letter Generator
  • A Library of Rebuttal Scripts
  • A map of Regulatory Agencies and their jurisdictions
  • Interest Calculation Resources
  • Access To Our Help Desk

To learn more about RevAssurance Online, pricing, and how to start your free 7 day trial, please contact revassurance@ernenterprises.org.

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