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Strategies for appeals of PRO payment denials
The Medical Staff Counselor
|March 5, 1991
Summary
Medicare payment denials for services can be appealed. Providers have a good chance of reversing these denials, ensuring proper reimbursement for patient care.
Area of Science:
- Health Services Research
- Healthcare Policy
- Medical Economics
Background:
- Peer review organizations (PROs) review Medicare patient care.
- Denials often occur when services are deemed "not covered" by Medicare.
Purpose of the Study:
- To inform healthcare providers about their right to appeal Medicare payment denials.
- To highlight the potential success rate of such appeals.
Main Methods:
- Analysis of PRO review outcomes for Medicare services.
- Review of denial and appeal data for Medicare claims.
Main Results:
- A significant number of payment denials are issued by PROs.
- Appeals have a high probability of success in reversing initial denials.
Conclusions:
- Healthcare providers should actively pursue appeals for denied Medicare payments.
- Understanding the appeals process is crucial for financial viability in Medicare participation.