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Practice Management Alert

6-Step Plan for Restructuring Your Appeals Process

Published on Thu May 01, 2003

If you don't have a policy for appealing denials, commercial insurance companies won't have a policy for paying you, and their payments will be similarly unpredictable and late.

To make insurance companies pay you fairly, consistently and promptly, restructure your appeals process with this six-step plan. Even if your office already has a handle on appeals, these tips will help raise your bottom line.

# 1. Focus on appealing one or two types of regularly denied services, says Thomas Kent, CPC, CMM, president of Kent Medical Management in Dunkirk, Md. Then appeal to one or two particularly stubborn insurers, he adds. Narrowing your focus will give you more time to compile effective appeals. Use specific cases as examples, but deal with the encompassing issue bundling, E/M requirements, etc. so the payer can't deny you on the type of service again, he says. Recognize issues clumped in denial patterns and address them.

Don't assume, however, that a pattern of denials automatically points to insurers' wrongdoings. Find out whether a denial pattern is suspect or whether it's warranted by checking it against regional, state and national billing patterns, says Jason R. Levine, JD, a consultant and senior editor for Murer Publications at Murer Consultants Inc., a legal-based healthcare management consulting firm in Joliet, Ill. You can obtain this information from your fiscal intermediary, he says.

You should also check to see if your coding patterns have changed over time, Levine says. These self-auditing steps will protect you from not only erroneous appeals but also fraud, a concern that repeated denials should raise for your practice, he says. Your office, intentionally or not, could be the cause of the denial.

When deciding which denials to focus on, ask yourself the following additional questions:

  • Which claims are worth appealing? You could appeal high-dollar amounts, but don't overlook the routinely downcoded E/M claims that cost you $25 each, Kent says. A $25 case billed four times per week could cost you $5,200 a year in denials, which is probably more than the infrequently denied high-dollar claim.
  • Which claims are the cleanest? Select claims that are clearly correct with sufficient supporting documentation and references you've copied, especially if you're a practice testing your appeals wings, Kent says. Check to make sure your patient demographics, diagnoses, services, code selections, documentation and modifiers are accurate before submitting an appeal, he recommends.
  • Are the providers behind us? The appeals you raise may land you into a protracted battle with tough insurance companies, Kent warns. Make sure your providers support you when you step to the plate, he says. Your providers  give the original documentation, so involving them in the appeals process will encourage them to improve that documentation. In addition, if your providers are enthusiastic about the appeals, their energy will filter through the staff that, in turn, will improve data entry and other tasks to help claims go out correctly the first time, he says.

    # 2. Identify and respond appropriately to the type of explanation of benefits (EOB) that comes with your denials. Refer to the third article for tips on responding to four EOBs.

    # 3. Append supporting documentation for your coding and billing choices to your appeals. You want to use outside sources whenever possible. Convincing sources for insurers include the CPT manual (make sure you use the correct year), ICD-9 manual, CPT Assistant, the Coder's Desk Reference, the National Correct Coding Initiative (NCCI) edits (even though they technically apply to Medicare, they support your argument), Medicare's local medical review policies (LMRPs) (even though they don't bind insurers, they support your arguments), and your national specialty society.

    # 4. Find out who at the insurance company will handle your appeal and then send that person a letter. Addressing your appeals letters to a specific person is important, Kent says, so someone is accountable for taking care of your request. In the introduction to your letter, state the service rendered and reasons for denial, and suggest that the insurer's computer system may be at fault. In doing so, you're offering them a "face-saving" way to resolve the problem, Kent says.

    In the body of the letter, explain your reasons for billing the ICD-9 and CPT codes you chose, quoting statements in the CPT manual or other sources if necessary, he says. Your recipient may not know much about this topic, so explain your position clearly and concisely, and bring in any support from Medicare and the federal government, Kent adds.

    Let the recipient know exactly how the insurer should pay the claim, especially if your contract explicitly supports your position. Don't leave it up to the insurer's discretion, he says. In the conclusion of the letter, include the filing deadline for clean claims in your state. Even if the deadline becomes irrelevant, you're letting the payer know that you're a "sharp, on-the-ball" practice that will fight inappropriate payment, he says.

    # 5. Take proactive steps to involve the patient. Patient approval can help support your cause, according to Kent. Send patients a copy of your appeals letter and send it quickly. The first side they hear from, you or the insurer, may determine which side they support, he says.

    # 6. Implement a good tracking system. Whether you're a computer whiz or paper loyalist, you should keep track of your appeals. Keep records of each patient's services, and keep those records under the appropriate appeals category, Kent says. File your records with a tickler filing system, and at the top of each file, note the patient's name, the date of service you're appealing, a brief overview of the appeal and the date you sent it, he adds. You should also run reports on your appeals, Kent says. You may want to consider investing in useful tracking software.
    Visit the Appeal Solutions Web site, www.appealsolutions.com, for low-priced software, says Teena George, a certified HIPAA specialist and owner of Humboldt Medical Solutions.

     

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