Otolaryngology Coding Alert

Do your homework to defend your reimbursement reasoning.

Although appealing denials isn’t convenient, winning them is an effective way to increase your otolaryngology practice’s bottom line. Plus, you can turn lemons into lemonade by using the experience to learn from prior mistakes and possibly avoid claim denials in the future.

Context: Denials have been steadily on the rise since 2016. But practices that appeal their denials typically have a high success rate, which can translate to a substantial return on investment (ROI) depending on the services your team is appealing, according to Holly Ridge, BSN, RN, CPC, CPMA, manager of medical necessity and authorization denials for Duke Health in Durham, North Carolina.

To give your appeal its best shot, here are five tried-and-tested tips for you to use the next time your practice receives a denial.

Submit Adequate Documentation To Show Medical Necessity

A provider must show medical necessity in the documentation and coding to receive reimbursement for the services performed. When a denial comes across your desk, you should review the claim to ensure that the diagnosis codes assigned show medical necessity for the procedures.

Remember: If the error is a simple matter, such as using a truncated diagnosis code when the record provides adequate medical information for a complete code, you can make that change yourself. However, some medical necessity denials will require additional information from the provider before you can file an appeal.

Create Appeals Templates To Ensure Consistency

“I very strongly recommend having templates … to ease [your] workload,” Ridge says. By having templates available, your staff will be able to plug the necessary information into the appropriate places and ensure each appeal is formatted similarly.

Examples of templates for different types of denials include:

• Authorization denials
• Medicare denials
• Commercial payer denials

“Templates look cleaner, more organized, and can look more professional. Templates can also help provide content reminders to staff as they write their appeals,” Ridge adds.

“Many electronic billing systems now include templates. Take advantage of these and have them prepopulated before they are needed,” advises Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia.

Support Your Case With Available Resources

Before submitting your appeal, you’ll need to defend your reasoning for reimbursement. “You really want to pull in any argument you can find that supports the … service … rendered,” Ridge notes.

Types of resources to use in your appeal with examples include:

• Payer policies: Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), commercial payer policies, Medicare Advantage policies. “Never assume a payer understands their own policy. Always send them all the information that supports your position and clearly explain it,” Joy says.
• State and federal regulations: Affordable Care Act (ACA), state definition of medical necessity, Emergency Medical Treatment and Active Labor Act (EMTALA), Employment Retirement Income Security Act (ERISA), Prudent Layperson Standard, applicable state laws, etc.
• Miscellaneous: Society guidelines/medical literature, National Correct Coding Initiative (NCCI) guidelines, peer-reviewed journals, professional organizations.

As you compile the different resources available to back up your appeal, you may need to consider the various costs of information. Some nationally recognized criteria may require a subscription fee, but medical literature and medical society guidelines could be available free of charge.

Keep Appeal Window Timeframes in Mind

When a claim is denied, you’ll have a certain timeframe in which you can appeal the denial. This appeal window may be between 60 and 180 days, or it could be as short as 30 days. The appeal window timeframe varies by payer.

Don’t miss: “All insurance policies that are a result of an employment benefit plan, which represents about 80 percent of plans seen by most practices — even if the employee has to pay 100 percent of the premium — fall under the ERISA law, which says that appeals have a 180-day timeframe. The federal ERISA law overrides any state laws and contract-imposed payer timeframes,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPCO, CPC-P, CPC-I, CENTC, CMCS, of CRN Healthcare Solutions in Tinton Falls, New Jersey.

Work queues may allow you to use a type of scoring to prioritize payers with a short appeal window. However, if you work manually, you’ll want to educate your staff on which payers have shorter appeal windows, so your staff doesn’t miss the deadline.

Pointers: It’s good practice to keep a spreadsheet of open denials with appeals deadlines, or to employ billing system software work-queue functions to manage deadlines,” Joy says.

“Another more efficient alternative is to use a bolt-on appeals management system, which supplements the functions of your practice management (PM) system, or to use a PM system that has an appeals management module,” Cobuzzi adds.

Analyze Why Claims Are Receiving Denials

One of the easiest ways to reduce your denials is by preventing them from the start. This can be done by analyzing your claims data to find denials that could have been avoided and prevented by making minor changes before the claims were submitted. Use the insight into why each payer is denying claims and how often to refine your processes and procedures.

At the same time, your analysis could show which types of appeals were successful and which denied services payers approved after a successful appeal. In those instances, you should continue to appeal those denials.

Plus, by analyzing your denials, you can focus on what to prioritize during appeals, as well as what improvements your practice can make on the front end through education, proper coding, and documentation to reduce the number of denials you receive.

Bear in mind: “Even with the cleanest of claims, third-party payers still deny clean claims that should have been paid during the first pass, hoping the practice will not appeal the denial — saving them the money that they did not pay in the first place,” Cobuzzi warns.

“Sadly, data shows that 50 percent of practices do not appeal these incorrect denials, and some that do appeal the denials do a poor job of making a case for payment, therefore helping third-party payers preserve their capital and creating revenue leaks for some practices,” Cobuzzi notes. “Do not let insurance companies continue to steal money from your practice! An effective appeals process will not only plug significant revenue leaks, but also boost practice income so that providers are being paid for the services they are providing,” she adds.

Tip: “You also want to have a strong assignment of benefits (AOB) to appeal for ERISA plans. Practices want to strengthen the AOBs that patients sign, giving them the right to ‘stand in the patient’s shoes’ when dealing with insurance companies so that the practice has all the rights that ERISA gives the insurance beneficiary (the patient),” Cobuzzi advises.