Practice Management Alert

When you bill a complicated specialty procedure and receive a denial that you know is unwarranted, a standard appeal may not be your best bet. You can request that the payer have a physician from your specialty review the claim and documentation.

Don't let just a carrier employee or a general physician (who can be any specialty) review your claim. Request that a qualified specialist review the appeal, because he would best understand the procedure your physician performed, the documentation, and the coding.

Bonus: Requesting a specialist is effective if the carrier is denying the claim on the grounds of medical necessity as well.

"You should ask for a specialist to review any appeal, not just those denied for medical necessity," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

In your appeals letter, be specific about why you disagree with the denial of the claim and why you want a physician specialist to review your claim. Appeal statements such as "Hi. We don't agree with the denial of this claim. Please reprocess" aren't as successful as more specific appeal requests, experts say.

Tip: You should be specific as to why the procedure was medically necessary and coded properly and thus fully payable. Include supporting documentation, such as the physician's notes. If you have examples of this type of claim being paid in the past by the carrier now denying your claim or even by another carrier, include copies of them in your appeal.

Good practice: Add a statement requesting a specialist review to every appeal letter you submit, Cobuzzi says. She suggests using wording such as: "Since the only physician who would be qualified to review these notes would be an XX specialist, we are requesting that these notes go to that specialist before a decision is made."