Claims Cost Containment

Patient Balance Issues
1. Balance billing by the medical provider 2. Negotiate the balance owed with your physician	Mistakes are often made by thePhysician or his/her medical billingoffice.  If you were balance billed for the difference between your contracted health plan and the amount of the payment, this is incorrect.  If you pay cash or owe a significant amount, attempt to negotiate a discount or payment plan.
Cash Pay Negotiations / Uninsured Patients
1. Uninsured patients should never pay the full charge 2. Negotiate the balance owed with your physician	Health plans don't pay the full charge to a medical provider and neither should you.  There are a variety of ways to either reduce the total amount you owe or increase the time you have to pay the outstanding balance.
Usual and Customary/Out of Network Denials
1. Usual and Customary Reductions 2. Patient received unexpected bill by an out of network physician	This is probably the most common concern among patients.  When a patient goes to a hospital which is contracted with their health plan and feel everything was taken care of, but then they receive out of network bills from the anesthesiologist, pathologist, radiologist, assistant surgeon and so on, which are reduced in payment due to Usual and Customary.
Health Plan Denied the Claim due to Medical Necessity
1. Denial due to lack of medical necessity 2.  Experimental/investigational denials 3.  Cosmetic denials	A significant number of claims denials are related to medical necessity, or the lack thereof.  The health plan is essentially saying that the physician or medical provider that treated you did so without a justifiable medical reason, or that it was cosmetic, experimental, or investigational. But, your physician may know best and if your physician properly documented his/her treatment of you in your medical chart, then this should always be appealed.
Lack of Authorization Denials/Non Participating
1. Non participating services received without a referral or authorization 2.  Non participating provider denial	Some health plans, especially HMOs, limit the availability of Specialists to their members, unless they seek an authorization or referral from theirprimary care physician.  This is done so that Specialty Care is not overused or used unnecessarily, as the cost of Specialty Care is expensive.
Emergency Room Denials
1. The health plan denied theEmergency Room visit 2. The health plan denied the transportation to an Emergency Hospital 3. The health plan did not authorize the emergency visit	Physicians and their billing offices must input all of the billing data into their billing system in order to submit a claim to your health plan.  During this process, a physician who may have been extensively trained in practicing medicine, may not have been as trained on preparing a bill to the health plan.  As a result, mistakes may occur in the preparation and billing of your claim.
Surgical Weight Related Denials
1. The health plan denied a lap bandsurgical procedure  2. The health plan denied a gastric bypass surgical procedure  3. The health plan denied anabdominoplasty	Health plans do not want to approve a claims payment for medical procedures that they feel are not medically necessary or potentially cosmetic in nature. The method of appealing these are to specify medical reasons of why the surgical procedure is required.
Timely Filing Denials
1. The health plan denied a claim that was billed on time  2. The health plan denied a claim that was not billed on time	One of the most common health insurance claim denials are those that are denied for being submitted late.  These can be appealed and won.  Some of the claims may be denied in error and you would need proof of the original claim submission to appeal.
Denials Related to Prescription Drugs
1. Drug is not on the health plan's formulary 2. The health plan denied authorization for prescription drugs 3. The health plan did not pay adequately compared with AWP	Health Insurance Companies have noticed a significant increase in the payments they have made towards Prescription Drug claims.  With this in mind, Health Plans have had to be creative in how they attempt to cost contain this benefit coverage.
The Health Plan Processed the Claim Incorrectly
1. The health plan paid the incorrect amount  2. The health plan paid the wrong person or medical provider	Today, many claims payments are made automatically, but still quite a large number of them are processed manually.  Due to this manual processing there are opportunities for making a mistake.  Some health plans have a better quality rating than others.  While one health plan accepts only a 2% error rating, other health plans may be ok with a 20% error rating.
The Physician/Medical Provider Billed the Claim Incorrectly
1. The wrong diagnosis, procedure code or place of service was billed 2. The wrong modifier or lack of modifier was billed 3. The claim was billed without a provider number	Physicians and their billing offices must input all of the billing data into their billing system in order to submit a claim to your health plan.  During this process, a physician who may have been extensively trained in practicing medicine, may not have been as trained on preparing a bill to the health plan.  As a result, mistakes may occur in the preparation and billing of your claim.
The Claim Denied due to Policy Limitations/Guidelines
1. An authorization was not obtained 2. The claim was filed late, causing a timely filing denial 3. The claim was appealed late, causing a timely follow up denial 4.  The claim was denied due to pre-existing 5.  The claim was denied due to a duplicate claim previously billed 6.  The benefit maximum was already paid 7.  The claim was denied as it was a non-covered benefit 8.  Lack of information caused the denial	One of the most frustrating denials and a type of denial usually overlooked, are those that are stated in a policy booklet, but not read by the patient or insured.  Individuals, prior to receiving an expensive medical treatment or have a lengthy hospitalization should always read the policy booklet to check first, if the medical procedure/service is a covered benefit, and second, to identify if there are any policy limitations or guidelines that must be followed in order for that service to be paid. http://claim789.blogspot.com/2014/07/how-to-boost-your-immune-system-and.html  HIT IT  http://www.empowernetwork.com/almostasecret.php?id=1210296 THIS IS THE PLACE hit it !!  Hey ,I have a better option for earning online , faster money making and highly systematic system designed especially for you guys ,  click here if YOU: WANNA GET YOUR DEBTS OFF ..                                  DRIVE A FERRARI                                  LIVE IN A MANSION                                  ENJOY ON THE BEACHES OF THE WOLRD !!

Smacking does children no harm if they feel loved, study claims

Smacking does children no harm as long as they know it is for the right reasons and feel loved, a study has found.

Being a strict mother can be good for children as long as the discipline is tempered with a little love and affection, the researchers claim.

But parenting groups and charities have reacted angrily to the findings, maintaining that a child can suffer long term damage from physical discipline.

The study of teenagers, published in the journal Parenting: Science and Practice, found the painful effects of harsh discipline - such as verbal threats or spanking - are offset by the child's feeling of being loved.

The researchers said being punished is unlikely to result in antisocial behaviour further down the line, as long as the child believes their punishment is coming from “a good place”.

Smacking is controversial and has been found to carry a greater risk of manifesting aggression, delinquency and hyperactivity - but authors claims this can be moderated.

In Britain parents are not explicitly banned from smacking their children, but under the current law it is illegal to inflict injuries causing more than a temporary reddening of the skin.

The research will fuel the debate and the parental concern over the best way of bringing up children.

Jeremy Todd, chief executive of charity Family Lives said: “We would never endorse smacking as we feel that there are much better ways to communicate with a child.

“Parents who contact us say that smacking comes as a reaction, it is not a controlled moment. They often speak of their regrets; it is not something they feel good about. We would not support the research.”

The team from the Albert Einstein College of Medicine in New York studied a group of Mexican-American adolescents and found having a loving mother - or the “perception of maternal warmth” - protected against antisocial behaviour.

The perception resulted in a positive relationship between harsh discipline and the way they way that the child dealt with problems in later life.

Dr Miguelina German, lead author, explained “attachment theory” holds that warm, responsive parenting is the critical factor in producing happy, secure children.

The underlying belief that their parents love them protects against feelings of rejection, even when being harshly disciplined, she said, and the discipline it does not automatically result in antisocial behaviour.

"The relationship between the two is conditional and subject to other factors,” she said, noting that restrictive disciples are the cultural norm in Latino culture.

“There are always other influences at play that can lessen their potential harm on the young child.”

However, a spokesperson for the NSPCC who have campaigned for the practice to be illegal, said: “Smacking is not an effective form of punishment and undermines the trusting relationship between a child and their carer.

“And it just teaches children to be violent. Young people tell us smacking leaves them feeling upset but often doesn’t deter them from doing what they were smacked for. We want to help parents use other more constructive methods to teach their children the difference between right and wrong.”

Previous research has found children are more likely to grow into well adjusted adults if their parents are firm disciplinarians.

Traditional “authoritative” parenting, combining high expectations of behaviour with warmth and sensitivity, leads to more “competent” children, according to the 2009 study by researchers from London's Institute of Education.

Justine Roberts, Mumsnet Founder, said: "Obviously smacking 'from a good place' is preferable to smacking 'from a bad place' but broadly Mumsnet users believe it's better not to use violence not least because it feels hypocritical to tell children one thing about hitting others, yet practice another."

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