Private Payer Resources

If a private payer inappropriately denies or bundles a procedure or service that you furnished, here are some steps to follow:

  • Please appeal the denial or bundling using the Academy’s position statements, CPT for ENT articles, and Clinical Practice Guidelines.
  • For payer issues you encounter on a state level, we recommend that you contact your state otolaryngology society or state medical society to report the issue, so they may assist you in its resolution. You can access the contact information for your state otolaryngology society on our website (Log in is required).
  • For issues with payer reimbursement on a national level, contact the Academy’s Health Policy department at Healthpolicy@entnet.org Once you report the issue, we will research it and determine whether we will pursue advocacy with the payer.

 

Additional Resources

Contacting Medical Directors: Article addressing factors to consider before discussing coverage decisions with medical directors

Medical Policies: Websites for the medical policies for national private payers

News and Updates: Includes important updates on coverage policies for national private payers

Appeal Template letters: Sample letters to assist with denials

American Medical Association (AMA): The AMA has established a very useful third party payer advocacy department that you can report coverage problems.  If you are interested in filing a complaint against an insurer, you can visit the AMA practice management center to obtain details on this process specific to the state where your practice is located.

Medical Group Management Association (MGMA): Practice management resources from the MGMA

Association of Otolaryngology Administrators (AOA): Practice management resources from the AOA

 

 

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