Published in Managed Care Business Week, May 8th, 2007
Insurance executives acknowledge that guidelines are not "binding" on medical reviews. Many applicable state and federal medical appeal review laws require consideration of clinical information submitted by the treating provider. As a result, guidelines are often set aside during the review process if justified.
"This is not just about winning an appeal and getting paid. Appeals indirectly shape the future of health care quality," said Tammy...
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