Practice Management Alert

A full-time appeals staffer is ideal

Starting this January, having your ducks in a row will be more important than ever before when you submit appeals for denied claims.

When the Centers for Medicare & Medicaid Services- new appeals process kicks in, billers will only have one chance to get appeals right.
 
Biggest Change Could Be Reduced Timeframes

If you don't include all the important information in your appeal to the Qualified Independent Contractor (QIC), you won't be able to add any more information except if there is -good cause.-

Another change is appeals timeframes: Starting in January, QIC appeals must be submitted within 180 days. And the administrative law judges (ALJs) who consider appeals after the QIC level will be Medicare specialists, instead of Social Security ALJs on loan.

Billing impact: All of these changes mean that billing offices should be ready to file faster, more accurate appeals in 2006. -You have to have your case better organized,- says attorney Alice Gosfield at Gosfield & Associates in Philadelphia. -You-re going to have to be much more on top of what you-re doing.-

In 2006, billers have to make sure their appeals have complete documentation the first time around, including all substantiating evidence, says Barbara Cobuzzi, president of CRN Healthcare Solutions in Tinton Falls, N.J.

Put Processes in Place and Appeals Get Easier
 
If you don't want to be caught off-guard by these changes, set up better processes to manage appeals so that every appeal runs more smoothly, Cobuzzi adds. -When you-ve got reliable processes, that's how you make sure you do things right,- she says.
 
You should have a checklist of sources to help you assemble documentation for every appeal--and also substantiating sources like the CPT Assistant and Medicare Carriers Manual to check in every case.

Research Cannot Wait Anymore

Due to CMS- policy alterations, up-front research on procedures and services that you may have to appeal is also vital, says Tammy Tipton, president of Appeal Solutions in Blanchard, Okla.
 
If possible, the office should have dedicated staff that work on appeals, Tipton says. Ideally, at least one person's time should be devoted entirely to appeals instead of having billers handle appeals as they come across their desks.

-They [appeals staff] can be more aggressively focused on having the documentation for that first appeal,- Tipton says.
 
Also, you may want to invest in -appeal management technology,- such as denial tracking software, so you know how much time has elapsed since the denial.

Changes Should Help--Once You-re Used to Them

After providers get used to the new appeals rules, experts feel that the appeals process will run more smoothly. Providers have been asking CMS to speed up the appeals process for a long time, says attorney Michael Manthei with Holland & Knight in Boston. -Overall for providers, it will be much better if [an appeal] goes quickly, even if it puts more of a burden on a provider to get his records together,- he says.

Most denials will be based on a sample of claims rather than a review of all files. Either that, or an automatic edit will deny a whole category of claims, Manthei says. Usually CMS will provide a spreadsheet with all the names and Medicare numbers of the patients affected. So it should be pretty easy for billers to look up these files, he says.