Fight Invalid Denials as a Team to Secure Your Practice’s Rightful Reimbursements

While appealing denied Medicare claims is a resource-draining task, the risk of doing nothing is far greater. In fact, if your medical practice can’t show that you attempted to appeal a problematic claim, you’ll appear to be unaware of potential compliance issues. That may be ironic, considering the fact that many denials – some say up to 30 percent – simply aren’t valid, but it’s an irony you can’t spend a lot of time crying over.

The best way to both make sure you aren’t missing out on your rightful revenue and avoid compliance problems down the line with the feds is to learn how to handle appeals as a team. The Medicare appeals process shouldn’t simply fall on one department’s lap. Everyone involved in your practice’s revenue cycle plays an important role in arming themselves with the knowledge to fight these appeals. Whether you’re a billing or practice manager, clinical or front desk staff, surgical scheduler, coder, or even a physician, you play a part in your practice’s Medicare appeals process.

Start With an Overview of Responsibilities

Whether your Medicare denials are due to a simple typo on a claim or a payer’s oversight, you have the right to knock on your carrier or intermediary’s door and argue your case.

As you step into the appeals process you need to ask some serious questions. For example, does your practice fully understand how the appeals process works? There are, after all, many details to consider. Maybe you need a fresh perspective on coding versus reimbursement, or a review of the elements that affect reimbursement. For example, correct coding alone does not assure proper reimbursement. It’s more an issue of the application of coding, bundling and medical necessity that dictates reimbursement.

So consider whether your entire staff is aware of their role in these processes:

  • Coding
  • Documentation
  • Collection
  • Reimbursement
  • Compliance
  • Patient privacy

Also, target the areas with the biggest appeal opportunities and train your staff on how to use payer appeal forms effectively. Don’t forget, there’s a difference between Medicare and private payers. Do you know how to tailor your appeal based on who’s paying you?

Appeal Through a Fine Tooth Comb in Steps

Now ensure that staff in each of the above areas can play their part to move an appeal along. For example, can your coders or billing staff read the denial codes on an EOB to determine the payer’s reason for denial or underpayment? That’s the first step to auditing the record to determine whether an appeal should go forward.

Another common issue you want to make sure is covered is whether you are required to use a payer’s appeal form. Who in your office is responsible for maintaining your contracts with payers? That person should be able to check off the next step of determining who the payer is and what it requires for its appeals process.

It’s a complicated process, but just knowing that you can break it down into discreet steps and assign everyone a role should make it not quite as daunting.

Educate Your Staff to Secure Reimbursements

Learn each step you need to take to secure your practice or facility’s rightful reimbursements in an audio conference for ProfEdOnDemand, “Medicare Appeals: Collect What Your Practice Really Deserves!” with coding and compliance expert Barbara J. Cobuzzi. From decoding state and federal claim processing laws to understanding common compliance issues, Barbara offers a plethora of must-have tips for filing an appeal. She identifies five formal appeal steps and walks you through what to do when an appeal is not successful. If you want to learn to work together as a team to secure the funds that are rightfully yours, you can’t afford to miss Barbara’s conference.

To join the conference or see a replay, order a DVD or transcript, or read more

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