Ophthalmology and Optometry Coding Alert

Question: An outside consultant recently came in to review our claims. She pointed out several that were paid incorrectly and advised us to appeal. We have never appealed before. What do we need to include on the appeals?

Maine Subscriber

Answer: You should contact your insurer to get the scoop on its preferred appeal process. However, in general, you should make sure your appeal letter references the initial claim. Although this sounds like a basic step, many providers forget to cite the claim number of the claim they are appealing, making it impossible for the insurer to address the right documentation.

As part of the appeal, the physician should write a strongly worded and educated appeal letter that’s tailored to each claim in question, along with an explanation of why the claim should be paid. For instance, if the claim was denied due to a lack of medical necessity, the physician can explain in their own words why this claim was medically required. They can send supporting documentation such as procedure notes, facts from medical journals, and information from Medicare decisions that support what they performed.

Be sure to file within the payer’s appeal timeline, because late appeals will usually get denied immediately. If, after submitting your appeal, you speak with anyone at the insurance company regarding the appeal, record the names, dates, times, and summaries of those conversations. This will be important if your claim has to go to the next appeal level.