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Battle Post-op Pain Without Opioids - April 2016 - Outpatient Surgery Magazine

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

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A regulated process Various state and federal laws protect healthcare providers and their "entitled" revenue against inappropriate handling of Medicare and commercial claims by insurance companies. In other words, it's safe to assume that your facility shouldn't be receiving less than the reimbursements you expected to earn on the date you rendered those services to the patient. A benefit denial is considered anything less than the contracted rate or clearly specified out-of-network benefit rate (for example, 60% or 70% of the total cost), taking into account any patient deductibles and reported co-insurance. A refund demand or recoupment is also con- sidered a benefit denial. In fact, the No. 1 denial in recent years is the "retroactive denial" that's then followed by a takeback demand by the payer. Insurance companies tend to handsomely incentivize recovery departments and third-party auditors to find overpayments and issue refund demands. This is how it usually works: An insurer notifies the facility and other providers of an alleged claim review, or it sends a request to review numerous medical records. This is then followed with aggressive repayment demands using fabricated allegations, ambiguous adjudication errors and misleading insurance policies. Regardless of whether the payer is contracted with your facility, there are explicit requirements that they must meet when it comes to denials and requests for recoupment. For example, when issuing a denial, payers must notify providers of their appeals rights, a require- ment that often gets ignored. Paying close attention to the denial and recoupment process may help your facility catch these missed prereq- uisites, providing more opportunities to protect your revenue. A P R I L 2 0 1 6 • O U T PA T I E N TS U R G E R Y. N E T • 3 3

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