Here are some of the strategies that we utilize to file an effective appeal and improve the odds that our physicians get the money that they deserve:
Identify
For each denied claim, ask, “why?” Remark and reason codes help explain the insurer’s reasons for the denial. If we discover that the problem is your error, we correct and resubmit the claim. (This may require a review of the documentation to determine if another diagnosis, for example, was substantiated but wasn’t included on the claim.) Just resubmitting the original claim without any alterations will not only cost you time, but it may also even raise a red flag for fraudulent billing.
Act
Set a goal of creating and submitting appeals within seven days of receiving the denial. Delaying the investigation and response just keeps that unpaid claim on your accounts receivable and raises your risks of missing the insurer’s timely filing deadline.
Investigate
An effective appeal is more than a letter demanding payment; it is an argument backed by evidence. Examine the insurance company’s rationale for denial. We make a list of the reason (or reasons) that we disagree with the insurer’s decision. This may require detective work: reading the medical record; reviewing the insurer’s provider manual; and seeking a clarification about why the physician selected and submitted the codes involved. If the denial was due to medical necessity, we will expand our investigation by talking to the physician who performed the service.
Respond
Although some denials may be reversed based on a telephone conversation, appeals often have to be put in writing. We review the basics of creating a professional letter. After a proper salutation, we’ll begin your appeal letter by referencing the patient, date of service and the claim number. Following this introduction, we’ll briefly describe the service for which payment was denied. We’ll keep the focus on recording our side of the story and making the case for payment, instead of demeaning the insurer for its actions. We’ll be sure to request a review of the appeal by someone familiar with your specialty, also known as a “peer-to-peer review.” (If the appeal is denied, this request allows you grounds to re-file the appeal if the reviewer was not an expert in the specialty, which is most often the case.)
Don’t let your appeal go into bureaucratic limbo by submitting it to the wrong place or otherwise incorrectly. Some insurers demand that you use their forms for appeals. Most have a designated address (physical and mail) for sending appeals. Some of this information may be included on the patient’s insurance card, but be prepared to communicate with the insurer to obtain the details.
Most insurers have multi-level appeals processes, all of which should be explained in writing in their provider manual. Understand the insurer’s processes and do not hesitate to take your case to a higher level if you are turned down.
Incorporate evidence
An effective appeal goes beyond opinion; it is accompanied by supportive references to objective sources, such as descriptions or guidance issued in the CPT Manual or other related AMA publications; relevant, peer-reviewed medical literature; we’ll contract with the insurer; the insurer’s published reimbursement policies – and perhaps even the insurer’s own marketing materials. Your practice’s internal quality guidelines may be useful, too. To refute a denial based on the necessity of a service or the need to have provided it as a distinct service, ask the physician to write a short description of the specific benefit of the service to the patient. Class action settlements between physician organizations and large insurance companies also may provide ammunition for your appeal, so check the Physician Advocacy Institute’s website. We’ll keep a copy of your letter, as well as the accompanying documentation, in the event that we need to create an appeal for a similar situation in the future.
Don’t forget
Once we submit an appeal, it’s important to determine whether it had any effect. We’ll set a reminder in your calendar to follow up in 30 days by calling the insurer. If they claim not to have received the appeal, we’ll ask to speak to a supervisor and get his or her fax number so we can resubmit the appeal that day (and call later to confirm that the fax was received). We’ll document the details of all of the conversations.
Log it
Closely related to setting a reminder for follow-up is keeping a log of all denials you receive and the appeals you file for each insurer. For each denial, capture the amount in question (the charge), the reason for the denial, and the important dates associated with each situation (date of service, date of denial, etc.). Add a column for the result – did your efforts pay off in the form of payment? At six-month intervals, review this log and the results. You may find trends, such as one insurer consistently denying certain types of claims. Alternately, you may find many insurers denying certain services, which may indicate a problem with your internal systems or coding practices. Of course, you also want to review how many denials you were able to get reversed – and the value of them. All of this data is important to review, periodically, with your physicians who may provide insight into denials that plague the billing office – as well as ideas for effective appeals. If possible, rely on your practice management system to track and report this important data, instead of creating and maintaining a manual log.
