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O C T O B E R 2 0 1 5 | O U T P A T I E N TS U R G E R Y. N E T
claims process.
One particular record warrants extra discussion: the assignment
of benefits. Without this document, you lack any means to receive
payment for an out-of-network insured patient. Instead, any pay-
ment you bill will be sent straight to the patient. A good assign-
ment of benefits is broad enough to cover a spectrum of rights
while also letting you take specific actions on behalf of the patient.
The courts have interpreted these assignments narrowly over the
years, so having a broad assignment giving you the right to bill,
collect and even sue on behalf of the patient is crucial.
Be timely
Failing to file a timely appeal of a denial is throwing away
money — and it happens more often than you would think. The tim-
ing of appeals depends on your status as an in-network or out-of-net-
work provider. In-network providers' agreements with payers govern
when an appeal should be filed. Out-of-network appeals must typical-
ly be filed within 180 days of the denial.
File appropriate documentation with your appeal
An appeal should be more than a perfunctory note saying, "I
appeal this claim." Instead, you should address the reason why the
claim is denied, as stated on the explanation of benefits (EOB). Then,
along with your appeal, you should submit evidence (studies and let-
ters of support, for example) supporting your claim.
This exercise will also help determine what appeals are worth the
time and energy. For example, it is not worth the effort to appeal a
claim where the patient's deductible exceeds the amount billed, or
where a patient's coverage has lapsed. However, if the denial is
because a procedure is "experimental and investigative" or "not med-
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