| Appealing denied claims used to be a simple process. | | | | - Copy and attach sections that support your case |
| A biller working with a physician's office would stamp | | | | from coding manuals, including past issues of the |
| "APPEAL" in big red letters on a photocopy of the | | | | American Medical Association (AMA) CPT Coding |
| claim, and mail it back to the insurance company. | | | | Assistant, a periodical that the AMA publishes to clarify |
| These days, you'd be wise to put the cost of that | | | | CPT codes. |
| postage in the bank, and throw away both the | | | | - For appeals that concern clinical issues (for example, |
| APPEAL stamp and its red ink stamp pad. This sort of | | | | medical necessity), send the appeal to the medical |
| knee-jerk response won't even make it past the | | | | director of the insurance company. |
| insurance company's initial computer screening; they'll | | | | - Look at the class action settlements between |
| likely toss such "appeals" into the trash and you'll never | | | | several large physician organizations and a number of |
| hear anything back from them. | | | | national insurance companies; review those |
| To successfully appeal denied claims, you need to get | | | | settlements to see if anything in there can support |
| your "A-game" on; otherwise, you won't see a penny | | | | your position. See the HMO Settlements site for |
| for your efforts. | | | | up-to-date compilation of the settlements, as well as a |
| Follow these steps to effectively appeal denied claims. | | | | list of pending lawsuits. |
| 1. Recognize denials. Insurance companies don't print | | | | 6. Confirm receipt. Don't just send the appeal and hope |
| the word "denied" in big letters across the top of the | | | | for the best. Review your submission online, or call the |
| claim form. In fact, the word "denied" may never | | | | insurance company to confirm that they received your |
| appear at all. The insurance company simply declares | | | | appeal, noting the name of the operator, extension |
| the reimbursement amount to be "$0" and enters an | | | | number, date and time. Place a tickler in your practice |
| adjustment reason code next to the amount paid. The | | | | management system or Microsoft Outlook to follow |
| key is to identify it as separate and distinct from a | | | | up in 30 days. |
| contractual adjustment, which is - and should be - a | | | | 7. Set boundaries. Although it might make you feel |
| write off. | | | | better to fight for every dollar, it doesn't pay to |
| 2. Understand why the claim was denied. Before you | | | | prepare a third-level appeal of a $2.41 service, |
| pick up the phone and demand to speak to the claims | | | | particularly if you only perform it once a year. Establish |
| representative, determine the root cause of the denial. | | | | protocols for dollar thresholds that you'll appeal only |
| You can't effectively appeal until you know why | | | | once, twice, etc. |
| payment for the service was denied. In addition to the | | | | 8. Don't go overboard. Avoid fighting for a claim that |
| reason code, there is a remark code. Look up the | | | | should have never been submitted in the first place, |
| insurance company's definition of that code to get | | | | such as an undocumented service. Your physician |
| details about the reason for the denial. WPC maintains | | | | may have provided the service and feels there should |
| a complete listing of standard reason and remark | | | | be some way to get paid, but - as the saying goes - if |
| codes, available on their website. | | | | it wasn't documented, it wasn't done. |
| 3. Don't procrastinate. There is often a timeframe in | | | | 9. Carbon copy stakeholders. Your appeal to reverse |
| which you can resubmit a claim after it's been denied. | | | | a denial is a matter between you and the insurance |
| Pull the record, research the code, call the patient, etc., | | | | company, but sometimes pulling in other key |
| but don't delay: most insurers only allow a few months | | | | stakeholders helps. Your first, and most important, |
| to resubmit a claim for reconsideration. | | | | advocate is the patient. Although patients may never |
| 4. Follow the insurance company's rules. Each insurer | | | | be held responsible for payment if a denial is ultimately |
| has an appeal process. The Centers for Medicare and | | | | upheld, news of payment disputes certainly get their |
| Medicaid Services (CMS), for example, has a form to | | | | attention. And the patient's attention is just want you |
| complete when appealing the denial of a Medicare | | | | want. Prompting the patient to contact the insurance |
| claim called the "Medicare Redetermination Request | | | | company directly to encourage payment doesn't |
| Form". Get familiar with the insurer's protocols to | | | | guarantee payment, but it certainly helps. |
| understand your options if your first appeal is turned | | | | 10. Develop supportive language in your contract. Your |
| down. Don't give up; most insurers have multiple levels | | | | contract establishes the relationship between you and |
| of appeals and even a grievance process if you | | | | the insurance company. Even though the insurer is the |
| disagree with the outcome after you've exhausted the | | | | party that typically presents the contract to physicians |
| appeals process. | | | | for their signature, it's every bit as much your |
| 5. Make a compelling case. An appeal means that you | | | | physician's contract as it is the insurer's. Proactively |
| disagree with the insurance company's decision, so put | | | | negotiate the inclusion of language that supports your |
| your debate cap on and gather supportive evidence to | | | | efforts to appeal claims. If you're frustrated by the |
| present your case. Perhaps the most important aspect | | | | appeals process itself or if you keep running into |
| of your claims letter is the content. The letter should go | | | | certain problems, such as unfair bundling denials, seek |
| well beyond stating, "please pay my doctor." Build a | | | | to include clearer definitions of these processes in the |
| compelling case for why the claim should be paid: | | | | contract. |
| - Develop a professional letter that begins by | | | | 11. Compile appeals. Appealing claims one-by-one may |
| referencing the claim number, date of service and | | | | get the results you need, but it is laborious. If you've |
| patient; then, briefly describe the particulars of the | | | | seen the same service denied for the same reason |
| service in question. | | | | multiple times - or your insurer hasn't paid in a timely |
| - Use the insurer's own language if possible. For | | | | manner, according to your state's prompt payment law |
| example, to appeal a claim denied because the | | | | - compile your appeals and present them together for |
| insurance company claims the treatment was | | | | reconsideration. |
| experimental, quote from the insurer's own marketing | | | | 12. Maintain a hassle folder for each insurance |
| materials where it declares it seeks to provide the | | | | company. Keep a record of denied claims - by dollar |
| best medical care for its beneficiaries. | | | | and type. Measure and compare the data on a |
| - When the insurer questions the necessity or | | | | quarterly basis. If you negotiated a good |
| separate payment for a distinct service, the physician | | | | reimbursement rate with an insurer, but all of your |
| should type or dictate a paragraph or two about the | | | | claims get denied, the "good" rate is meaningless. It |
| benefits of the service to the patient. Seek objective | | | | pays to maintain a record of reimbursements and |
| evidence to support your case from your specialty | | | | denials in order to effectively review your contract for |
| society and medical literature. | | | | its strategic contribution to the practice's bottom line. |
| - Look to see if Medicare or Medicaid pays for the | | | | Preventing denied claims is a key skill of successful |
| service; if they do, you can argue that even the | | | | billers. But getting some denials will always be a fact of |
| government has determined that payment is | | | | life in today's complicated physician payment system. |
| appropriate. | | | | Appealing denials is your right: it pays to exercise it. |