Ophthalmology and Optometry Coding Alert

Hint: Try and open communication lines with payers.

“Time is money,” the old saying goes, and that has never been truer than when medical practices have a stack of denials piling up. You want the money that the appeals could net you, but you don’t want to spend the time to process them.

Unfortunately, you don’t have a lot of alternatives to appealing your claims — but you can make the most of the time you do have by processing your appeals efficiently.

How Much Are Denials Costing You?

It takes between $25 and $30 to manage the average denial, and those can multiply quickly, said Angela Boynton, MSJ, BS, RHIT, CPCO, CPMA, CCS, CPC, COC, CPC-P, CPC-I, director of compliance with CVG Corporate, during the May 30 Eye Care Leaders webinar “Increase Revenue by Better Understanding Healthcare Payment Practices.”

“It’s very, very important to have a strong denial management practice,” Boynton said. And handling denials shouldn’t just start when the claim is actually denied — instead, it should begin long before you receive a denial in the first place.

“Part of a strong denial management process is trying to anticipate some of these causes and trying to avoid them on the front end,” Boynton said. Prioritization is also important, she added, especially if you have quite a few denials on your plate. “There’s not going to be an instant fix – you probably won’t see fixes in a month or even six months, depending on the volume of denials you’re dealing with.”

When you’re preparing to prioritize your denial process, keep in mind that high dollar amounts usually equate to high efforts, Boynton advised. You have to decide at the beginning if you want to work those high dollar claims even though they may take longer to turn around, or whether you want to focus on low dollar claims since theoretically you’ll have a much faster turnaround with faster cash influx, she said.

Know the Claims, Denial, Appeal Processes

Before you get started on your appeals, you should ensure that you have a solid understanding of the claims, denial, and appeal processes. “The majority of payers try to use auto adjudication systems with three levels of review for a claim before you get to a denial where you’d have to appeal it,” Boynton said. The initial first pass is that claim you submit to the payer, which is scanned at intake by a computer.

When the computer scans the claim, if something doesn’t make sense, the claim won’t necessarily be auto rejected, but will often be sent to human eyes. “If it still doesn’t make sense, at that point it will either go to another viewer or you may see it bounce back to you saying there’s an issue with the claim, or in some cases it could be denied,” she said. In some situations, you can file a reconsideration, but if it’s a true denial you have to work an appeal.

Every payer is required by law to offer an appeal, but the question is often how many stages of the appeal process exist. Typically, payers have three appeal levels: Internal review, where the payer looks at the letter you sent and reexamines the case; then the second level, which involves review by a clinical staff members; followed by the third level, which is an independent review by a neutral third party that will look at the claim and make a determination.

Follow These 4 Steps to Successful Appeals

Boynton offers the following four stages that will help your appeals move through the process more quickly and efficiently:

1. Cite the Claim You’re Appealing. “One of the most common things I saw during my many years as a claim reviewer for payers in Massachusetts was when providers would send appeals and would forget to reference or cite the initial claim they were trying to appeal,” Boynton said. “This is hugely problematic, so please don’t send an appeal in if you’re not going to reference the original claim you’re appealing because the payer will have no way to track that.” In addition, sending an appeal letter without citing the original claim will prompt an immediate denial, thus forcing you to waste one of your appeal opportunities due to a simple-to-fix error.

2. Draft A Clear Argument. “I cannot stress the importance of a refined, strongly-worded, educated, and crafted appeal letter, because too often what we see in the industry is that a provider will simply use a template or canned appeal letter and they use the same script over and over again,” Boynton said. She recommends that practices create an easily customizable appeal letter for a variety of specialties and appeal types, which can be quickly tailored to the specific appeal with details and citations.

3. Support Your Case With Regulatory or Clinical Facts. To bolster your chances of winning an appeal, you should cite facts from factual documents, such as Medicare LCDs, CPT® Assistant articles, or AHA Coding Clinic articles, Boynton said. You can also include clinical data from peer-reviewed journals or articles from a specialty organization, among other documents. Don’t be afraid to cite the law when you can. “Sometimes citations can help you open a door of conversation with a payer because open communication is such a strong tool in the denial management process,” Boynton said. “We see enough of the ‘us vs. them’ mentality in healthcare, so when we’re working an appeal, we want to open up those barriers and lift that veil to communicate.”

In addition, make sure you cite compliance or regulatory rules when warranted. “Believe it or not, compliance or regulatory issues are almost becoming neck-in-neck with clinical and medical issues when it comes to appeals,” Boynton said. Citing these resources can be a big motivating factor in getting payers to change their minds.

4. File Appeals on Time. Every payer in the country has a limit for filing appeals, so keep careful note of when your appeals are due at each level and make sure you meet those deadlines. “Don’t be late, not even by a day,” she said.

Documentation Is Essential

You know that maintaining documentation of patient visits is essential, but many practices don’t maintain strong documentation during the denial and processes. This can be a mistake, Boynton advises. “As you begin the process of working appeals and trying to have a payer reverse their decision, you need to be documenting every single contact you have with the payer during that event,” she said. “Record names, dates, times, and synopses of the conversations. Treat every appeal as having the opportunity to land in front of a judge.”