MYTHBUSTER: Does the ALJ system work?

MYTH:  The ALJ System doesn’t work.

FACT:  The ALJ System DOES work.

In a case study, a patient was referred to the provider’s emergency facility by her primary doctor, for evaluation and treatment of coughing, wheezing, and shortness of breath with respiratory distress with suspicion of pneumonia. the provider called the patient’s health plan and spoke to a case manager nurse who stated it was okay to admit the patient and requested for a fax sheet to be sent. The patient was then admitted into the facility pursuant to the health plan’s verbal authorization. The next day, the patient was discharged with no disapproval of care from the MAO. 

Two months later, the provider received a denial for the patient’s stay. After months of upholding the same denial, ERN requested an ALJ hearing on behalf of the provider. 

In January 2015, ERN received a Notice of Hearing with the scheduled hearing date.

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.