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Part B Insider (Multispecialty) Coding Alert

APPEALS:

Know the Difference Between a Review and a Fair Hearing

Published on Tue Oct 21, 2003

Overwhelm carriers with facts and legal background, not emotion

So your local carrier has kicked some claims back to you, and you're staring at your broken dreams of reimbursement.

Luckily, there are things you can do to rescue the situation and get those claims paid after all.

  • Understand the difference between denials and audits. For a claims denial, you can request a review, then go to a fair hearing and finally to an administrative law judge, says attorney Alice Gosfield with Gosfield & Associates in Philadelphia. But with an audit, you don't get a review before you have to go through the more formal fair-hearing process. The carriers used to allow reviews for audited claims, but most of them stopped a couple of years ago on the grounds that the audit was the same thing as a review.

  • Know the difference between a review and a fair hearing. If you're dealing with a denied claim and can ask for a review, you may have some flexibility to ask the carrier to rethink its decision. A carrier review is "still a formal process. It's not a wheedling, begging and groveling process," Gosfield says. But you can certainly get the attention of carrier personnel if you can make a strong argument as to why they should pay your claim.

  • Make sure the carrier staff know that you're knowledgeable. "What you want to do is not so much establish a friendly relationship as establish one of your knowledge and authority on claims processing issues," says Tammy Tipton, president of Appeal Solutions in Blanchard, Okla. If you educate the carrier staff correctly on issues, "they develop a feeling that they have to pay your claims," she says. People in provider offices often assume carrier staff will be more knowledgeable than they are, but in fact carrier staff may not know state and federal laws as well as providers do.

  • Get your ducks in a row for a fair hearing. Make sure the fair-hearing officer has all your documentation, supporting statements and explanations that put your claim in "the best light possible," Gosfield says. FHOs are "bound by the record of the information you submit" and then they may consult with other physicians, but you won't be there to defend yourself, she says.

  • Know your history. Especially when communicating with carrier staff in a review, cite as much past history as possible of similar claims that were paid, Tipton says. Talk to your state medical society about recent changes in the law that may be relevant.

    "You've got to cite some persuasive information to get them to reconsider," Tipton says. If you're citing legal authorities or medical policies, you can often get the carrier review staff to send your letter to an attorney or the carrier medical director.

  • Avoid form letters. Carrier staff can spot a form letter requesting a review a mile away, and they reward that lack of effort with their own lassitude, Tipton says.

     

     

     

     

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