Reader Question:
The Four Levels of an Appeal
Published on Sat Jul 01, 2000
Question: Would you please explain the four levels of appealing a claim?
Wisconsin Subscriber
Our appeals experts suggest four levels of appealing a claim:
1. At the first level, or review, the neurosurgeon 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 neurosurgeon may move on to the second level of appeal.
2. The second level is called fair hearing. At this stage in the process the neurosurgeon 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, ask where the specific coding pair in question originated. If it is not an national Correct Coding Institute edit, there may be a greater chance that a carrier medical director will rule in the neurosurgeons favor.
3. The third level is the administrative lower judge level appeal. The neurosurgeon 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.
4. The fourth level is the appeals council and it is very rare that an issue is taken to that 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.
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, and a coder who specializes in surgical and neurosurgical procedures, reports that a recent statistic states 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 neurosurgeon. If a carrier enforces policies that a neurosurgeon believes are unfair and change cannot be effected on the carrier level, the neurosurgeon also may consider getting in touch with his or her state or national neurosurgical associations to lodge a complaint and learn if other neurosurgeons are facing similar problems with the carrier on a state or nationwide level. The neurosurgeon also may file a complaint with his or her states insurance bureau.
