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Appeals: the last word.

A Lewis1

  • 1Peer Review Analysis, Inc., Boston, MA 02116.

Medical Interface
|July 7, 1994
PubMed
Summary
This summary is machine-generated.

Appeals of denied precertifications pose risks for managed care organizations due to legal and financial pressures. This review suggests low-risk protocols to improve enrollee satisfaction and reduce liability.

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Area of Science:

  • Healthcare Management
  • Health Law
  • Managed Care

Background:

  • Denied precertification appeals receive limited industry attention, often due to favorable liability regulations under ERISA.
  • Emerging legal precedents, accreditation standards, and physician incentives for cost-saving may increase risks associated with current appeals practices.

Purpose of the Study:

  • To review common precertification appeals practices that carry significant risk.
  • To propose cost-effective protocols that mitigate risk and enhance enrollee satisfaction.

Main Methods:

  • Review of existing precertification appeals practices.
  • Analysis of legal, regulatory, and financial factors influencing appeals risk.
  • Development of alternative, lower-risk appeals protocols.

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Main Results:

  • Certain standard and investigational appeals protocols present considerable risk.
  • Low-cost alternative protocols can effectively minimize risk.
  • Implementing these protocols can lead to increased enrollee satisfaction.

Conclusions:

  • Managed care organizations must address the risks associated with precertification appeals.
  • Adoption of revised, lower-risk appeals protocols is recommended.
  • Strategic changes in appeals management can improve both risk mitigation and patient experience.