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3 thoughts on managing denials from employer plans

Submitting a clear and convincing appeal is getting harder for ASCs. Not only do surgery centers have to consider complex contracts with government payers, but also variances within appeal limits, state regulations and, increasingly, employer policies.

Here are three thoughts on managing employer plan denials from Kylie Kaczor, MSN, RN, vice president of clinical and regulatory affairs at National Medical Billing Services, and Scott Allen, vice president of managed care contracting at National Medical Billing Services. The executives presented their advice to attendees at Becker's ASC 25th Annual Meeting: The Business and Operations of ASCs in Chicago.

1. ASCs must remember they have the opportunity to appeal directly to the employer or the employer group. Not doing so and appealing directly to the insurer could result in a waste of time and resources for the facility. In addition, including Employee Retirement Income Security Act language in the appeal letter can help ASCs expand their rights.

2. "With self-employed plans, patients will present you with an insurer card that has one of the major insurers on it. So it will look like, talk like and walk like a standard health insurance plan," Ms. Kaczor said. "However, with self-funded plans, the insurer is acting in administrative services only. It remains the responsibility of the employer to pay those claims — and for the ASC to recognize this."

3. "Even in the past two or three years, we've had to adopt a number of different strategies to make sure that the patient we see, their payer ultimately pays their claim properly," Mr. Allen said. "The way the healthcare landscape is changing, it's important for ASCs and the front desk to understand that there is an employer behind the insurance payer. UnitedHealthcare, Cigna, Aetna, the Blues — we have to start looking behind that insurance payer and ask, who is really paying that claim?"

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