Oncology & Hematology Coding Alert

Former payer rep reveals the tactics that work.

Want to get better at appeals? Take some advice from someone who knows how the other half lives - and works.

During her career, Annie Boynton, MSJ, RHIT, CPCO, CPMA, CCS, CPC, CCS-P, COC, CPC-P, CPC-I has worked for physician practices and for a major insurer, so she has lived and worked both sides of the appeals struggle. At the American Academy of Professional Coders Regional Conference in Salt Lake City in October 2017, Boynton presented a session for coders, billers, and practice administrators who want to get better at working appeals from the physician side. We've gathered Boynton's best tips here for you.

Step #1: Do everything you can to avoid having to appeal in the first place. It costs between $25-$30 dollars to manage each denial you get, Boynton said, citing statistics from the Medical Group Management Association. Make sure your oncology practice has systems in place to ward off the most common reasons for denials:

• Incorrect contractu al adjustments;
• Medical necessity;
• Service lacks prior authorization or referral;
• Utilization review;
• ERISA;
• Duplicate submissions;
• Eligibility, coverage, or benefit issues;
• Billing specialty test services inappropriately;
• Forgetting or misinterpreting the global period;
• Medicare and MSP rules;
• Timely filing issues; and
• Errors on claims - missing, illegible information or transpositions.

In addition, monitor your denial stats carefully to make sure payers haven't launched new edits that are triggering denials for your practice.

Step #2: Make sure you have a signed authorization from every patient that gives your practice permission to represent them in an appeal. The easiest way to do this is at intake: have all of your patients sign a form. To create a form for your practice, you can use templates available from Medicare (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf) or your state, and then customize the templates for your practice. (It's a good idea to have your attorney or in-house counsel review the form.)

If you have signed authorizations on file, you always have a counter-argument for one objection some payer reps provide to rationalize why they can't review the appeal - that "because of consumer protection regs," they can't share data with you. A signed authorization helps you bypass this objection and move on with the appeal, Boynton said.

Step #3: Know your payer contracts inside and out and tailor each appeal for the payer to whom you're appealing. "No two payers handle appeals the same way, so you shouldn't use a cookie-cutter approach to appeals," Boynton said. To understand a particular payer's appeals process, start with the contract. Do you know where it is? Are you confident you have the most recent contract on file? (Payers' rules change often.)

If it feels like too much of a burden to slog through the contract, remember: The more time you spend preparing the appeal at the front end, the less time you spend fighting with the payer later, Boynton reminded AAPC attendees.

Step #4: Learn as much as you can about the human element of appeals. Your contract with the payer is just the tip of the iceberg. To make shrewd decisions, you need to go much deeper. You need to understand how payers operate, who's reviewing what and when, and how each person encounter can and can't help you.

Understand the limitations of your payer's customer service representatives (CSRs), Boynton advised AAPC attendees. CSRs aren't coders and billers, and most are kids still in college who are reading scripts. If they tell you they can't answer a question and are "escalating" it for you, they're typically passing you to someone else in the CSR department with 10 additional hours of training. They aren't the folks processing your claims, and at many payers CSRs aren't even working in the same building as claims processors. Typically, the information a CSR can provide is limited to claim receipt and whether it's in adjudication.

During claims adjudication, claims generally pass through a computer with an optical reader program. When the computer kicks out a claim, it typically goes to human readers who aren't coders. If the humans can't resolve the problem, they suspend the claim.

Every payer's appeals process is different, but generally there are three levels:

• First level, internal appeal: Reviewers are usually high-school educated folks without much coding, billing, or healthcare experience.
• Second level, internal appeal: At this stage, the claim hits coders, auditors, or nurses. There may be one or two levels of internal appeal, depending on the plan type and design. If specialty knowledge is required to review the appeal at this stage, you have the right to ask for the reviewer's medical qualifications. Ask about their education level, and ask whether the review was condition- or case-specific, Boynton suggested.
• Third level, external appeal: This is the only review that must occur with someone outside the health plan. Hence the term "external review."

Helpful hint: As you learn more about the human element of your payer's organization, resist the urge to demonize them - no matter how frustrated you become during the appeal. Remember that many are folks similar to folks who work in your office, many have worked in physicians' office themselves, and many belong to professional organizations like the AAPC or the American Health Information Management Association, Boynton reminded attendees.

Plus, if you get to know payer reps as people, the whole process may become easier. Make small talk and develop genuine personal relationships with your payer counterparts, Boynton suggested. What begins as small talk can end up as substantive discussions to help you understand what happens to claims upon payer submission, who the medical reviewers are and how you can contact their reviewers. You may end up with direct line numbers and other tools that make the appeals process less arduous.