Oncology & Hematology Coding Alert

Plus, a handy template that will help you write the perfect appeal letter every single time.

During time working for a major insurer, Annie Boynton, MSJ, RHIT, CPCO, CPMA, CCS, CPC, CCS-P, COC, CPC-P, CPC-I, saw lots of appeals from lots of providers. Some letters and packets did their jobs extremely well, and some were so weak they might as well not have been sent at all. At the October 2017 American Academy of Professional Coders Regional Conference in Salt Lake City, Boynton taught attendees how to assemble an appeals packet that gives providers the best chances of winning an appeal.

Use These Tips for Writing Good Appeals Letters

"You'd be surprised at how many appeal letters fail to mention what is being appealed," Boynton exclaimed. An appeal reviewer who is working under a quota will not spend time tracking down a claim number that you have forgotten to mention, so remember to clarify all those details.

Don't dash off a canned form letter, even if the payer is sending you its own canned form letters, Boynton advised. Customize the body of your appeal letter to succinctly and thoroughly describe what happened and why you think it should be covered.

Don't let your frustration get the best of you, Boynton urged. Your letter should stick to facts and logic. Short factual statements are more likely to win appeals than letters that are long, full of emotion, or digress into commentary that isn't relevant to the claim.

Here's an Outline to Get You Started

[Practice/Doctor Name]
[Address]
[Date]
[Address of your health plan's appeal department]
RE: [Name of the Insured]
Plan ID #: [123]
Claim #: [456]

To Whom It May Concern:

Dr. XXX is requesting a review of your denial of [coverage, pre-authorization, or other] of the treatment prescribed and rendered by Dr. XXXXXX on [date] for [treatment] of [patient's name] [name of disease or condition].

BODY OF LETTER

We ask that you reconsider your previous decision based on the information above. Included are several journal articles supporting the use of [name of procedure] for [patient's name] [name of disease or condition]. They are numbered 'Journal 1' and 'Journal 2' for your convenience.

Sincerely,
[Your name]
[Your contact info]

Make the ACA Your Appeals Ally

There's a lot not to like about the Affordable Care Act (ACA), but it has its advantages for appeals. The ACA spells out specific appeals rights for providers, and payers are seeing more appeals that cite compliance with the statute, Boynton said. At 45 CFR § 147.136, the ACA statute describes provider rights to external review during an appeal, she explained. This section outlines the process for bringing in a neutral independent review organization (IRO) to resolve the issue. (Note that because an IRO's decision is binding, you can't appeal the claim after that.)

In addition to the ACA, your state may have external review regulations that further support your provider's right to appeal.

Throughout the letter, use phrasing that signals to knowledgeable reviewers that you're aware of the ACA's requirements. Such phrases can work to grab a reviewer's attention, escalate the appeal to a higher level, or invite the payer to join you in a logical dialogue about nuts-and-bolts policies.

Boynton suggested you use phrases such as these in your appeals letters:

• "In order to seek a transparent process ..."
• "It is our understanding that disclosure of XXXX provides all parties with ..."
• "Our understand of XXXX citation is..."
• "It is our position that treatment follows evidence-based standards of care ..."
• "Please find enclosed patient authorization for our practice to represent them during this process ..."

Don't Forget Supporting Documentation

"When I was working for a major insurer, I often saw appeals with no supporting documentation except for the provider essentially saying 'pay me,'" Boynton told AAPC regional conference attendees. "Appeals are time-consuming, so if that's all you're going to do, you might as well not bother to appeal."

According to Boynton, your appeal packet should include:

• Method of tracking for the payer (patient ID, claim form, etc.)
• Payer's appeal form

        ○ Supporting documentation including:
          ♦ Medical record documentation
          ♦ Documentation from:
              • Peer-reviewed journals
​              • Pub 100 references
​              • CPT^® Assistant
​              • Payer's policy
​              • ICD-10-CM specific policies
​              • Letter of appeal

Tip: A common denial reason from payers is that the treatment is experimental or investigational. To counter, pull and append data from other states that show other payers are paying.

And finally, make copies of everything you send, of course. Sometimes payer reps "lose" letters and supporting documentation. If you suspect that the payer is disorganized or stalling deliberately, you can send the appeals packet via certified mail, Boynton suggested.

Resource: To read the part of the ACA that spells out providers' appeals rights, go to: https://www.law.cornell.edu/cfr/text/45/147.136.