Hospitals Sour on Medicare Advantage: 8 Things to Know

Jakob Emerson

With the Medicare open enrollment period underway, some seniors may have fewer provider choices in their respective regions as hospitals and health systems across the country increasingly cut ties with the Medicare Advantage program ...

Clinical Validations Target Sepsis Diagnoses Without Sep-3; More MDs May Move That Way

Nina Youngstrom

When Erica Remer, M.D., was a young physician, the way she knew a patient with an infection had sepsis was “you walked into the room and got the sinking feeling the person would die from this infection ...

ALJ Overturns All Malnutrition Denials in Hospital Appeal; CMS Has 'No Official Policy' 

Nina Youngstrom

Although the wheels of administrative justice moved slowly for a set of Medicare claims ...

Certain MA Rule Language 'Give You Much More to Work With' in Appealing Claim Denials

Phillip Baker, M.D., Bill Hayes, Kendall Smith, M.D. 

Although the world opened up for hospitals and other providers with the April regulation that requires ...

2024 Medicare Advantage and Part D Final Rule

Denise Wilson, MS, RN, RRT 

On April 5, 2023, CMS issued their final rule on Medicare Advantage (MA) and Part D plans...

Tiffany Ferguson, LMSW, CMAC, ACM and Denise Wilson MS, RN, RRT 

The need for benchmarking denials is evident...

Strategic alternative dispute resolution offers providers key to substantial claim recoveries

Lawrence A. Laddaga, JD, FHFMA, and Julia Dandridge | From the HFMA

Strategic alternative dispute resolution offers providers key...

Patient Noncompliance May Be Grounds to Overturn Readmission Denials

Nina Youngstrom 

Report on Medicare Compliance, Volume 31, Number 23, Published by the Health Care Compliance Association, Eden Prairie, MN

Appeal Writing 101

 Taryn Schraad 

Not to mince words, but medical insurance claim denials are a “thorn in a provider’s side.” Meticulously getting the the admission or diagnostic services authorized or approved, then providing care and treatment to the...

Appeals Shortcut –
Orthopedic Surgery 

R. Kendall Smith, MD, SFHM Chief Physician Advisor, Intersect Healthcare

Quite often appeal writers are faced with the challenge of...

Top Tips for Successful Clinical Validation Appeal Arguments

Breen Nabors, RN, CCDS 

The dreaded denial letter comes across your desk disputing a major diagnosis that undoubtedly will...

How to Handle Payer DRG and SOI Denials that Provide No Detailed Explanation

Malissa Powers, BS, RHIT, CCS, CDIP, CICA

Although the payer should provide a detailed explanation as to why the...

Clinical Validation Denials- What Are They, and What Are They Not

 Karla Hiravi, BSN

In the medical denials and appeals world, a clinical validation audit is done to ensure billed diagnoses and conditions are validated by the...

Cut your Workload and Win More Appeals with Appeal Letter Templates

Denise Wilson

There is never a reason to write an appeal letter from scratch unless you are writing your very first...

Why You Should Include Payer Coverage Guidelines in Appeal Templates

Denise Wilson

Including payer coverage guidelines in your appeal letter templates can increase the efficiency and...