Know the Five Key Steps to Successfully Appeal Denials
Published on Sat Jul 01, 2000
Insurance denials for ethically claimed services are an irritating and somewhat frequent occurrence for practices, many of which spend hours each week appealing these claims. Practices that have a person who tracks common denials and speaks directly with claims managers may find that is a better use of their time than sending standard appeal letters with a copy of the patients chart.
For instance, some practices report denials when billing for a consultation during surgery with frozen section(s) (88331) on the same day as a later, intraoperative consult (88329). Although the consult service is bundled with the frozen section in CPT 88331 for one patient session and one surgical site, there are instances when a pathologist is involved in more than one consultation for the same patient on the same day.
If a pathologist is called to surgery for a consultation involving a frozen section to establish a diagnosis of neoplasm of the colon (88331), for example, and later is called back into surgery to consult on margins of the colon resection (88329), both services should be billable with the use of modifier -59 (distinct procedural service). If the insurer denies a claim such as this, the following tips should help practices more effectively deal with appeals:
Step One: Know Your Insurers Appeals Method
According to L. Michael Fleischman, CHC, principal of Gates, Moore & Company, a healthcare consulting firm in Atlanta, many practices arent familiar with their insurers appeals guidelines. The appeal process may be different for each carrier, but it should be in their provider manual. Read the contract to learn how to proceed after you receive a denial. The insurance companys provider manual should be specific in spelling out the method for appealing claims.
Step Two: Ensure You Billed Accurately
Many denials can stem from errors within your own practice, says William J. Mazzocco Jr., PA-C/RN, president of Medical Administrative Support Services, a healthcare consulting firm in Altoona, Pa. Simple things like forgetting a modifier can result in denial, so its important to review the patient information in your office before you begin any appeal process.
Mazzocco suggests that practices review patient information to ensure that procedure codes, diagnosis codes and modifiers are correct, and that the claim was sent to the correct insurer. For example, if Medicare denies a claim for a man who hurt his back lifting a box at work, instead of just appealing it, look back at your notes. You may realize that it should have been sent to workers compensation first. Or if Medicare pays only part of the claim for a stroke victim, you may realize that the patient has a secondary insurer who should receive the claim [...]
