Practice Management Alert

A lot of time and energy is dedicated to appealing denied claims, so it's important for billing offices to know the best route to success.
 
The appeals process can be a huge headache, but it is necessary to ensure profitability. After all, if you let every denial go unchallenged, you'd be missing out on thousands of dollars to which your practice is entitled.
 
To make the process as efficient as possible, billers must arm themselves with all the information they need to emerge victorious. The biggest mistake people make is failing to send in adequate records to support their claim, points out attorney Lester Perling with Broad & Cassel in Ft. Lauderdale, FL.
 
For example, take the case of a denied claim for an ultrasound. On appeal, the billing office might send in the written report of the ultrasound, but neglect to include the note from the previous month's visit that indicates the pain that necessitated the ultrasound, Perling offers. Without this supporting documentation, you won't win the appeal. You often need to look at the entire patient record to provide medical necessity for the claim in question, Perling emphasizes.
 
Tip: Highlight the portion of the patient record that justifies the service being denied, or state it in a cover letter. "Don't rely on the reviewer to find what you want them to find," he advises. Instead, "point them to what you want them to find." If you don't want to include the entire record, write up a short synopsis of it to include with your appeal, Perling suggests.

Follow These Real-World Strategies for Success

Navigating the waters of Medicare appeals can be a daunting prospect for the most seasoned of veterans, and can seem downright overwhelming for people new to the process.
 
Erica Schwalm experienced this when she became the compliance officer and reimbursement specialist for Pioneer Spine & Sports Physicians, P.C. in West Springfield, MA. She found herself faced with a mound of downcoded evaluation and management claims that needed appeal. However, she plunged right in and has won every appeal thus far. Here's how:
 
Step 1. "The first thing I did was research, research, research," she tells Medical Office Billing & Collections Alert. You can't win unless you know the rules ... so read up. Especially focus on E/M coding guidelines, she suggests.
 
Step 2. Design an E/M auditing tool. Schwalm devised a four-page tool, covering the history, exam and medical decision-making. The tool also includes a cover page, which summarizes the findings of the audit (see "Cover Your Bases With This E/M Audit Cover Sheet" for a sample). Using this tool, she audited each claim that had been downcoded, spending between 30 and 45 minutes on each initially, but getting faster with time. You can design your own tool to match your practice's needs.
 
Step 3. Send the information to the payer. Schwalm included a copy of the completed audit tool, a cover letter and the appropriate supporting documentation with each appeal. "I won every single appeal I did," she reports.
 
One last hint: Watch your attitude. Appeals can be very frustrating, but no good will come of "getting hostile" with the reviewer, Perling concludes.