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International Medical Group Case Study

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Denying or closing out the claims for the Top 9 diagnoses will affect several Departments (areas) within and outside of International Medical Group® (IMG), Inc. The Departments (areas) are below with explanations of how why they could be affected.

Operations
• The mail volume may increase due to the insured/provider submitting appeal letters and/or claims resubmission.

Marketing
• Increase in phone calls and emails from brokers/producers due to their increase of phone calls/emails from their client requesting a clearer explanation of the claim denial.
• Increase of unhappy broker/producers once they determine IMG is not doing their due diligence in conducting an investigation before denying the claim.

Call Center
• Increase in phone …show more content…
 Is it acceptable to use the existing remark codes that reflect claim is denied for pre-existing condition?
OR



o Claims closed with a request for medical records.

 Is it acceptable to use the existing remark codes for requesting medical records?

OR

 Create a new remark code services that reflect the claims that are denied and/or reconsidered for the automatic denial for pre-existing conditions be created? The new remark codes series may help for actuarial purposes to determine the impact his new process has impacted the overall denial ratios, costs of handling, service levels, etc..

6. Will a Mail Merge letter be mailed to the insured stating claim was denied due to a pre-existing condition along with an explanation of what is required to reopen and/or appeal denial?

7. To be proactive, will the claim examiner complete a Pre-Existing Checklist and forward the claim to Team Pre-x?

8. The Benefit Review team responds to the appeal advising medical records are required to review the appeal (or the medical records received are under review); they will forward the documentation to Team Pre-x for …show more content…
Call Center

1. Customer Care staff will need a link placed on their desktop to the Top 9 Diagnosis Codes for them to review at the time of the call.

2. Verification of Benefits

• Is the Call Center state to the provider that they are not able to provide benefits due to a pre-existing condition?

OR

• Quote benefits read the Pre-existing Disclaimer, state the medical condition may deny due to the Pre-existing Clause of the Certificate, and suggest to the provider to submit complete medical records with the claim.

• Possible issues of asking the provider to submit medical records with the claim.
 Provider may charge for the medical, which in turn, increases IMG’s costs.
 Records may not be complete because they may only send the records for that particular date of service.

3. Pre-existing Alerts

• There is a strong possibility that an increase of pre-existing alert requests by the Call Center staff will occur due to the specific diagnosis list. The current process for handling of the pre-existing alerts should not

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