Practice Management Alert

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 [...]