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Thursday, July 31 2014

News for Fighting Medical Claim Denials Thanks to Obamacare

Your NJ attorneys are here to keep you up to date with new information and updates in New Jersey legislation.Because American medical insurance is a hot topic in 2014, Degrado Halkovich of Hackensack, NJ wants to inform you of options you may have if your insurance carrier has denied you of treatment or medical reimbursement.

Andrew Miller, the medical director for Healthcare Quality Strategies of East Brunswick, gives Americans details on The Affordable Care Act's ability to challenge an insurance carrier's medical claim denial. Contact your personal injury attorney in NJ for more information.

Obamacare Rules Right to Challenge Medical Claim Denial

Source: NJ.com

People who have never been insured before may not be aware they have a right to challenge an insurance carrier's decision to deny treatment or reimbursement. The Affordable Care Act guarantees access to an independent review if people are not satisfied with the findings of the company's own appeal process. Andrew Miller, the medical director for Healthcare Quality Strategies of East Brunswick, a nonprofit firm hired by the U.S. Centers for Medicare and Medicaid Services to improve New Jersey's Medicare program, described what consumers can expect.

Q: How are appeals judged?

A: (All decisions) are based on the medical record to determine whether care is necessary, appropriate and provided in the appropriate setting ... The medical record should document the reason for care, what they are treating and why.

Q: How does the appeals process work?

A: It starts within the company denying payment or treatment. They are required (by state law) to have this system in place. (The doctor) says we think this is necessary; the company will say they will look at it. If they come back and say we are sticking by their decision, the patient can say I want to appeal this to the next level. Sometimes there is another level of appeal in the company. A doctor who may not be a specialist in the same area as the doctor providing the care may do the (initial) review, but at the second level, they may give it to a specialist who works for the plan.

If the plan says no, we are sticking by the original decision, (the consumer) says I would like to request an external appeal. This is performed by an objective body that doesn't have any conflict of interest regarding the decision, and that is making an objective decision. Again it's based on what is in the medical record. At each level, you can provide additional information. But it's not like a court proceeding with back and forth arguments.

Q: How will the consumer know what to do?

A: The carrier passes on how it works.

The consumer is filing the appeal, but it's really between the provider of care — the hospital or doctor not getting paid — and the insurance carrier. The provider has to be keeping those records, and the patient doesn't have a lot of control of how much detail is being captured and the rationale documented in the medical record.

If you are insured through the ACA, this process has to be in place, but in New Jersey, it's not a new process. The state Department of Banking and Insurance has a process, rules and a time frame for doing that, which is now extended to additional people covered by the ACA.

To find out more information or the rest of the article, click here.




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