Practice Management Alert

Your appeals success rate depends on the details Even when you think you-ve done everything right -- double-checked diagnosis codes, included detailed patient information, gotten a signed advance beneficiary notice (ABN), etc. -- Medicare may still deny your claim. When you know that Medicare should pay the claim, use these checklists to get all the money you deserve. Helpful hint: You don't have to appeal a denial if you find you-ve just made a mistake on the denied claim, according to CMS. Just ask your carrier to reopen the claim so you can correct the error. Checklist 1: Determine the payer made an error If you receive a denied or underpaid claim, you first have to make sure that the denial isn't a result of the way you filed the claim. To do so, follow these steps outlined by Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders in Salt Lake City: - Read denial codes on the remittance advice to determine the payer's reason for denial or underpayment. - Audit and review all of the coding documentation. - Make sure the documentation supports what was billed. - Determine that the payer made an error. Once you-ve determined that the payer made an error, you can write a letter expressing why you think your carrier should pay the claim. Just remember that Medicare requires that you file your request within 120 days of the date of the initial determination notice. Check with private payers to find out their time limits. Checklist 2: Follow Medicare's style Medicare prefers that you follow certain guidelines when you write appeal letters, so start off on the right foot by writing your letter correctly. Medicare needs to handle these letters as quickly and efficiently as possible, so correct style will help the reviewer focus on your appeal rather than getting tripped up on your style. Be sure to use the following guidelines: - Keep the language simple. - Do not use abbreviations or jargon. - Write in a positive -- rather than negative -- tone. Avoid words or phrases that emphasize what cannot be done. - Avoid one-sentence paragraphs and uneven spacing between paragraphs. Checklist 3: Use the correct letter format Like correct style, correct formatting allows the reviewer to get to the heart of your letter -- your appeal -- more easily. Implement these style conventions to ease the appeals process: - Use the date format April 20, 2007, instead of 4/20/07. - Use at least a 12-point font size, and stick with the Universal or Times New Roman fonts. - Use bullet points to clarify lengthy or complicated subject matter. - Use headings to [...]