Reader Question:
The Four Levels of Appeal
Published on Thu Jun 01, 2000
Question: We have several claims that we believe have been unfairly denied by carriers. What are our options for appealing a claim?
California Subscriber
Answer: Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, explains that the first two levels of appeal are carrier appeals.
At the first level, or review, the neurologist is asking the carrier if the claim was processed correctly according to the carriers guidelines. If the carrier says that it was and refuses to pay, the neurologist may move on to the second level of appeal.
The second level is called fair hearing. At this stage, the neurologist may ask the carrier to take a closer look at the carriers guidelines to ensure that these guidelines were developed fairly. For example, if bundling issues are involved, physicians can ask where the specific coding pair in question originated. If it is not a national Correct Coding Initiative (CCI) edit, there may be a greater chance of a carrier medical director ruling in the neurologists favor.
The third level is the administrative lower judge level appeal. The neurologist appears before a judge, is sworn in and gives evidence. The judge has discretion to determine if the policies being applied are appropriate. Testimony also may be given by an outside medical expert who doesnt necessarily work for the carrier.
The fourth level is the appeals council and issues rarely are taken to this level. If the appeals council sees that some error was made at the administrative lower judge level, they will not make a decision. Instead, the appeals council will remand the matter back to the administrative lower judge for a reappraisal.
Sandham reports that a recent statistic stated that the administrative lower judge process is running 564 days from filing to decision. Because an appeal must be made on each individual claim, taking matters to this level can become time and cost prohibitive for the neurologist. If a carrier enforces policies that a neurologist believes are unfair and change cannot be affected on the carrier level, he or she also may consider contacting the state or national neurological associations to lodge a complaint and learn if other neurologists are facing similar problems with the carrier on a state or nationwide level. The neurologist also may file a complaint with his or her states insurance bureau.
