After a 3rd level appeal

Hello,

I was wondering if anyone had experience with denials from commercial payers that goes beyond the 3rd level of appeals.  We are getting response letters that state "completion of a level 3 dispute exhausts internal administrative rights."  Curious what other hospital systems are doing with this.  Anyone willing to share their current process?

Thank you!

Comments

  • Hi Cdrum,
    There are limited options after a level 3 commercial denial, but what I suggest is to rate your denials to see the ones that were incorrectly denied and pursue a legal escalation process to get the maximal ROI. Hope this helps. 
  • I have been currently investigating this topic as we have received several egregious denials. What I have found is this:

    -Payors generally have an appeals "policy" that someone in revenue cycle can direct you to

    -Our payment manager suggested to call the insurance company and request to speak with a manager and discuss situation

    -As part of the contracting services, there is usually a customer service representative that a payment variance manager can contact and discuss the case with (after all appeal processes have been completed)

    We have gotten some really inappropriate denials particularly from a company called Cotiviti and so far every appeal has been upheld, we have not exhausted out efforts. Some of these accounts are large dollar accounts and I will recommend legal action if we cannot come to a resolution. Many companies do include in their contract thought that prohibit legal action but allow arbitration from an independent source.
  • Given Cotiviti is not the payer, but a contractor for the payer, you will have multiple levels of appeal for DRG downgrade denials and following your denials, you have the option to have a peer to peer like call. You can take it up to 5 levels and the peer to peer as a level 6. 
  • How do you go about getting 5 levels plus the peer to peer?  The contractors for the payers do not provide this information.  We rarely deal with Cotiviti but do a lot with UHC and Amerigroup vendors.  When I call to inquire, its usually 2 - 3 levels only.  Is it based on our contract with the managed care company?  I'm in NJ so we are able to take our Managed Medicaid denials to External Arbitration through Maximus / PICPA which we have been very successful with.  Our Managed Medicare  are not eligible for External Arbitration through Maximus. I'd love to know how to get the peer to peer option. 

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