Billing & Reimbursement: Make Over Your Appeals Process , And Give Your Bottom Line a Face-Lift

If you're like most hospitals, you're losing loads of reimbursement to denied claims many of which could easily win appeals. Fight back with these five appeals strategies to earn well-deserved payment and eliminate your billing staff's fear of "no."

Attack One Item at a Time
 
Facilities often shy away from appeals because they think the task requires a lot of investigation and paperwork for doubtful return. But if you focus your appeals program on a few types of regularly denied services or procedures at a time, and direct your appeals to one fiscal intermediary (FI) at a time, you'll cut the job down to size and create more effective appeals. 
 
Once you've reviewed your data, determine patterns that lead to repeated denials in specific areas, says Rebecca Buegel, RHIA, director of HIM and privacy officer at Casa Grande Regional Medical Center in Casa Grande, Ariz. Then target individual problems for example, are a significant number of denials due to coding errors? Does a particular physician's documentation consistently leave out elements crucial to coders? Are claims with certain diagnoses repeatedly rejected?

Know Your Insurer's Quirks
 
Each insurance company's provider manual should spell out the details of what steps you need to take to appeal claims. But the process can vary from one FI to another, so be sure to familiarize yourself with FI-specific guidelines before you go knocking down doors.
 
If the mistake is in the coding, some FIs will let you simply correct the error and resubmit the claim, but others are pickier and may require further explanation no matter how small the problem. Non-Medicare insurers have more informal appeals processes, but, on the flip side, they also tend to have shorter time limits in which you can file (60 days, as compared to Medicare's six months).  
 
You need to be especially aware of your denials if your insurance company reviews claims concurrently, because the FI may deny claims that don't have all the relevant information attached yet. "The physician may add documentation in later like a discharge summary that pulls together a lot of information," Buegel says, "and the insurance company may not have seen it, since they were doing a concurrent review."

Have Your Story Straight
 
Before you contact the insurer, find out if the denial resulted from an error on your side. For example, you may have forgotten to append a modifier. Review the patient's information and make sure the procedure codes, diagnosis codes, and modifiers are right, and of course, that you sent it to the appropriate insurer. If it's Medicare, the denial code will tell you the reason for rejection.
 
Check if the patient has more than one insurer if so, is Medicare one of [...]

- Published on 2003-06-01