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Tools for Overpayment Recovery & Claims Appeals

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Addressing claims payment issues can be complicated, but ensuring proper processing and payment of health care claims is vital to the financial health of a practice. The AMA offers resources to help physicians secure correct claims payment from health plans, navigate the overpayment recovery process and appeal incorrect payments.

Overpayment Recovery Toolkit

Attempting to determine the validity of alleged overpayments can divert significant time from direct patient care, resulting in lost practice revenue. Overpayment demands may be made in very general terms and can be intimidating. However, it is critical for practices to effectively and efficiently address overpayment recovery requests.

To help physicians understand health insurer overpayment recovery requests, the AMA created the Overpayment Recovery Toolkit (PDF, members only), which consists of the following resources:

Appealing Claims Payment Issues

Physicians generally collect the majority of their revenue from health insurers. To maximize revenue and maintain financial viability, practices need to ensure that health insurers are properly adjudicating their claims and should be prepared to address/appeal any improper health insurer payment adjustments. To help physicians understand and enact efficient appeals processes, the AMA has created the following informational resource and sample appeal letters:

Identifying and Appealing Health Insurance Claim Payment Issues (PDF, members only) helps physicians implement an effective and efficient claims review/appeals process:

Sample Appeals Letters

AMA members can download these sample letters and customize them in their practices.

Authorization and Eligibility

Contractual Obligation

Medical Necessity

Payer-applied Edits

Prompt Payment

General

AMA members can also access the National Managed Care Contract Database, where they can look up state laws and regulations to copy and paste into their appeal letters.

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