Practice Management Alert

Attack that stack on your desk and watch the money come in.

So many busy people have to-do stacks on their work desks that hobble their productivity. But if your to-do stack is full of denials you’ve been meaning to appeal, get inspired by these tips and dismantle the pile and all the guilt and anxiety that it holds.

Give Payers What They Want

It’s easy to miscommunicate if you’re speaking a different language. Make sure you understand exactly what a payer requires — and then format your appeal letter and claim accordingly.

“Look at the remarks codes on the explanation of benefits and address those specific edits,” says Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at CodeCast, in Laguna Niguel, California.

“Don’t hand them back the same medical record, they’re just going to deny it again. Address the remarks codes; the missing information and bundled services are a lot of the common reason for claims denials. Payers often look for additional diagnostic information or an additional op report or lab report or result and won’t pay the claim until they receive this documentation,” she says.

The explanation of benefits (EOB) or explanation of Medicare benefits (EOMB) will be your compass rose in navigating the error codes or denial codes that you need to understand and utilize in order to get your claim and appeal processed successfully. The error or denial codes are often at the bottom of the EOB or EOMB, Fletcher says.

Watch Out for Bundling

Many claims are denied because of incorrect coding — due to bundling. This could be another example of accidentally not speaking the same “language” as the payer, and it’s easy enough to correct.

“Go back and look at your IntelliCode or Alpha2 or CCI [Correct Coding Initiative] edits,” Fletcher says.

Do a mini investigation, asking, “Is this actually bundled? Is this something we should have billed? Did we use the right modifier?” she suggests.

“Address those edits, those specific denial codes, and when you look at those you’ll actually be heading in the right direction,” she says.

Utilize Regulations, Correct Citations for Context and Support

While making sure that your appeal is legitimate, your responsibility includes due diligence on research. Citing proof that you’re playing within the rules protects you and boosts your appeal, but it also means holding up your contractual obligations.

“You also want to make sure, if you going to give an appeal letter or cite an appeal letter, that you’re giving regulation. There’s nothing worse than when I see a practice saying, ‘You need to pay me because you didn’t pay me before,’” she says.

“I had a practice that didn’t like their fee schedule; there was nothing wrong with the claim, they got paid what their contract was, but they said ‘Yeah, they didn’t pay us enough, so we went ahead and rebilled it and asked for money,’” Fletcher recounts.

“I was like, ‘OK, wait, if you sign that contract and you didn’t negotiate, prior to signing that contract, a better rate for yourself, you’re kind of stuck with that rate.’ So those kinds of things should never be in an appeal letter,” she says.

Bottom line: “We want to make sure we are using that regulatory information, citing CPT®  language, and that’s one of the best ways to fight claims. It tells you directly what you can and can’t do and it also basically gives you the language to use within your appeal letter,” Fletcher says.

Bring in the Patient

One may forget that the patient is central to the whole claim/denial/appeal process. If you stay on top of your denials and appeals, you have more time to involve the patient, if necessary, which could mean a better outcome for both the patient and your practice.

“Remember you’re appealing on the behalf of the patient, who’s the actual subscriber, so ask for specific internal criteria on which the payer is basing the denial. This information goes beyond the reason-denial code, and it can also help providers craft an argument to fight the denial,” she says.

Another hint: Utilize other resources within your practice.

“List your midlevel providers; a lot of time your midlevel providers can give you that clinical piece that maybe you don’t have as a coder or biller or a collector. They’re usually more open and usually have a little bit more time to approach them with information,” Fletcher says.

Know Your Contractual Rights

Figure out who is reviewing the claim and issuing the denial. If the reviewer’s credentials don’t necessarily suggest a knowledge base or background that are qualifying to understand the procedure or encounter in question, you have an avenue forward.

“Demand a peer review” in these cases, Fletcher says.

Many denial letters are signed by nurse case managers. If your practice is a specialty practice or your clinicians perform surgery, a nurse may not have the expertise to really understand the minutiae and nuance of the encounter described in your claim. In cases like these, you may need to get a physician involved.

“It’s in every payer contract: A physician in the same specialty with the same credentials reviews the appeal,” she says. If your physician can make a case for medical necessity, demand a peer review and use the extra time to make sure your physician documented everything comprehensively and properly.

“Instead of relying just on the nurse-case manager, make sure you’re looking for the peer review, because that’s going to make a huge difference when it comes to getting the outcome that you want in that collection process,” she says.