Learn Insider Tips & Tricks For Launching A Successful Appeal Of A Denied Claim

No healthcare provider is immune from claims denials. But if you take the right corrective actions and draft an appeal letter using certain strategies, you can recapture the reimbursement you deserve.

If your medical practice faces claims denials, you’re not alone – but you can recoup your lost revenue by drafting an appeal letter that will get results, according to healthcare attorney Thomas Force, Esq., in his audio conference, “How to Draft an Effective Appeal Letter.”

Look For Mistakes – Big And Small

Problem: When you receive a claim denial, simply sending a balance bill to the payer along with an explanation of benefits (EOB) is a mistake, according to M-Scribe. You should send an appeal letter, so that you can spell out what you want the payer to review, such as coding denials or fees. Although putting the request in writing can take a little more time, it can make a significant difference in the success of your appeal.

Solution: The first step in filing an appeal is understanding the reason for the denial, which you can find in the EOB or the denial letter, stated Genetech Access Solutions. Make sure you identify the payer-specific appeals process and associated deadlines.

Look closely at the remark codes, so you’re addressing those specific edits, advised Medical Economics. Study the claim and medical record to look for any missing information, including lab or operative reports. Don’t resubmit the same medical record without correcting mistakes or filling in the information gaps, because the payer will just deny the claim again.

Crucial: Always make sure that you’ve corrected the claim if the original contained mistakes or was incorrect. Check the claim’s CPT coding, documentation, diagnoses, and EOB for accuracy. Be sure to double-check any modifiers used in the claim to ensure that you’ve appended them appropriately – adding a modifier simply to get your claim paid could put you at risk for an abuse or fraud investigation.

Don’t overlook: Look for simple mistakes, too – these are often the root cause of many denials. Was the claim completed incorrectly or illegible? Did you miss filing deadlines or fail to obtain a pre-authorization? Was there insufficient, non-existent, or incorrect documentation? Ensure that you identify and fix these types of simple errors before you attempt to appeal the denial.

7 Components To An Effective Appeal Letter

So when you’re ready to sit down and write the appeal letter, what kinds of information should you include? Genetech recommends that you provide the following seven items:

  1. Patient information, including full name, date of birth, insurance ID number, insurance group number, and case ID number.
  2. An introduction stating the appeal letter’s purpose, including the reason for the denial and indication that you’re familiar with the plan policy.
  3. A summary of the patient’s diagnosis(es) and the indication for the services, treatment, procedure, or medication.
  4. The clinical rationale (medical necessity) for the treatment, services, procedure, or medication.
  5. An explanation of why the plan’s preferred treatment(s) are not appropriate for the patient, if the payer denied the claim based because the treatment is “not covered.”
  6. A summary of your recommendation and the clinician’s recommendations.
  7. Additional disclosures, including (where applicable):
    • The Letter of Medical Necessity;
    • Prescribing information;
    • Clinical notes/medical records;
    • Diagnostic test results;
    • Scans showing progressive disease;
    • Pathology reports;
    • Relevant peer-reviewed articles;
    • Clinical practice guidelines; and/or
    • FDA approval letter.

Know The Root Cause

Mistake: Don’t try to bill for anything that you can’t support with medical documentation. The notes must prove that the procedures, services, or treatments you’re reporting were actually performed. Look at the medical record and physician’s notes (not just the note summary) carefully to make sure you’re capturing all the procedures and services performed, while not reporting anything that isn’t supported in the documentation.

Bottom line: Always remember that the key to writing a compelling appeal letter and winning an appeal is to understand why the payer denied your claim in the first place – so you can provide the necessary evidence to show your right to payment, notes Thomas Force in his audio conference.

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

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