January 13, 2023 | By J. Paul Spencer, CPC, COC
A major change to appeals submissions is set to begin on February 1st, 2023 that will effect practices and facilities across the country.
United Healthcare (UHC) is mandating the submission of electronic reconsiderations and appeals for most types of claims and plans under their banner. This change is announced here.
In anticipation of this change, UHC has created an interactive guide to online reconsiderations and appeals. This guide is in the form of a series of four videos that is referred to as a “course”. Videos include the following topics:
- “Find Your Claim”, which is self-explanatory;
- “Take Action on Your Claim”, which provides guidance on how to request a claim reconsideration, as well as how to submit an appeal;
- “Check the Status of Tickets”, which shows how to check the status of reconsiderations or appeals; and
- “More Information”, which provides some online resources and an opportunity to submit feedback on the process to UHC.
In addition to step-by-step instructions for the submission of appeals, and as part of their move to electronic claims reconsiderations and appeals, UHC has introduced an Application Programming Interface (API), that enables the opportunity to submit reconsiderations and appeals through a practice management system (PMS), or, in the words of UHC, “any application you prefer”. There is a link to the API Marketplace, which, after entering an ID and a password, takes you to an area that enables the user to register a system or application for the interface.
As I typed the paragraph above, my thoughts immediately turned to medical groups and practices who have A/R functions handled by third-party billing companies. If your PMS is in the hands of such a company, and UHC is one of your major payors, it is extremely important to do a baseline compliance check for both entities.
The Office of Inspector General first released compliance guidance for third-party billing companies in December of 1998. Given that we are now almost a quarter of a century removed from the first release of this guidance, there is literally no excuse for any third-party billing company to exist without a dynamic, ongoing, evolving compliance program. This is particularly true given the new-found ability to transmit appeal information electronically through a practice management systemPMS that is not under your control.
This is also an opportune time to remind the reader that as part of the Affordable Care Act, every medical practice must have an active compliance program. One cannot demand a culture of compliance from their business associates without first demanding the same of themselves.
Understanding that we are a week removed from this change taking place at UHC, it is important to state that this should be viewed with the “canary in the coalmine” mentality. If one of the largest commercial and Medicare Advantage insurers is taking their reconsiderations and appeals to the electronic space, every other commercial carrier is probably not far behind. Change in our industry is at once uncomfortable and inevitable. UHC’s move to electronic reconsiderations and appeals is but the latest change.
Your next steps:
- Contact NAMAS for information about customized staff and provider training.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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