Practice Management Alert

If your billing department never considers appealing a Medicare claim even when you're sure the denial is inappropriate you could be missing out on deserved revenue. Although billers generally agree that Medicare is a responsive and fair payer, its carriers make mistakes.
 
"I hear people say that they don't bother to appeal Medicare claims, and I can't believe it, because that's money," says Terry Murillo, business office manager of the seven-physician Atlanta Pulmonary Group in Atlanta. "It may not be a lot of money, but a lot of little bits add up. If people don't bother to appeal when they think they've been wrongly denied, it's no wonder the rest of us have to fight harder because even Medicare is scrutinizing claims more and more."
 
When you get an explanation of benefits (EOB) from Medicare in which a claim you think should be paid is denied, don't roll over and play dead, agrees Cam McClellan Teems, senior consultant and billing and collection specialist with Gates, Moore & Co. in Atlanta. If your claim is denied because of an error, such as an incorrect modifier or diagnosis code, learn from your mistakes and make sure you file clean claims. Don't continue to file claims that have erroneous information on them, she says, because it needlessly costs you time and money to refile the claim, and delays receiving the correct payment. When your claim is denied for reasons other than mistakes, such as services determined to be "not medically necessary" or services deemed as "incident to" procedures, and you're confident that determination is incorrect, stand up for yourself and appeal, she advises.
 
The key to successfully appealing a Medicare Part B claim in which the denial is based on more than a simple mistake is understanding the appeals process and meeting the requirements of each step along the way. Medicare regulations allow providers and beneficiaries who are dissatisfied with a claim determination to have it re-examined. That re-examination can continue through five different levels, beginning with a review of the claim by the carrier and ending with a federal district court hearing, if certain criteria are met. (For more on the Medicare appeals process, see page 35.) Most practices, however, resolve their problems at the review or fair-hearing step.

If you believe a claim is error-free but not paid as it should have been, you should take a step before starting the Medicare appeals process, and ask the carrier why the claim was denied, Teems recommends. "Often, the descriptors on the remittance or EOB aren't clear, and you can understand it better when you hear it from the person on the other end of the phone," she says. If you discover during this phone call that an error did occur, ask to correct it then. After you hear the specifics about the denial, if you still feel the denial was incorrect, highlight the line item on the remittance and make a note that you need to examine the supporting documentation. Document the call by writing down the name of the person you spoke with, the date, the time, and the information you were told about the claim. Then, gather your documentation to support the claim and your appeal, including operative notes, office notes and medical journal articles if appropriate.
 
The first step in the Medicare appeals process is the review by the carrier. A review must be requested within six months of the date of the initial determination on the claim. Most requests for review are done in writing, but CMS permits providers to request a review by telephone if the appeal is not complex, and some carriers accept appeals at the review step on the telephone. Ask your carrier whether you must appeal at the review step in writing. CMS requires that a written review be filed within the timely-filing period if the appeal from a provider is complex or if significant documentation is needed to adjudicate the appeal.
 
You can request a review by completing CMS Form 1964, Request for Review of Part B Medicare Claim, or by sending a letter to the carrier and submitting your supporting documentation with it. Few practices use the form because they find it confusing, Teems says. "The form is misleading to the average practice because it looks like something a beneficiary, not a provider, would use to refute a denial of a claim," she continues. But, when a provider accepts assignment, that provider is acting on the beneficiary's behalf and may use the form, she adds. Also, the CMS communications about the form are ambiguous. For example, Program Transmittal AB-00-122, dated Dec. 7, 2000, states: "A request for a review may be filed on Form 1964, Request for Review of Part B Medicare Claim; however, a signed written statement expressing disagreement with the initial determination or indicating that a review or a re-examination should be made, and containing the necessary information constitutes a request for a review."
 
"This language is very unclear to the average reader," Teems says. "Does it mean that you can use form 1964, but a written statement is the only form that constitutes a request for a review? On one hand they have an official form. On the other hand, they will accept a request for a review on the practice's letterhead. But the request for review does have to include certain items." Teems recommends using form 1964 to ensure you include all the required information.
 
Tip: To download a copy of form 1964 from the Internet, visit www.hcfa.gov/forms/default.asp and click on HCFA 1964. The form is in pdf format and requires Adobe Acrobat software to open. Adobe Acrobat can be downloaded from our Web site at www.codinginstitute.com at no charge.

If you send a letter requesting a review, attach the EOB or the provider-remittance advice with the claim in question highlighted or marked and supporting documentation. Make sure the letter uses language that is specific to the service or services denied, and explains the request for the appeal, Teems stresses.
 
The language in your letter is important because the Medicare Carriers Manual instructs carriers on how to proceed based on the letter's content. For example, if the letter is limited to a request for an explanation, the manual instructs carriers not to consider the letter a request for a review. "A letter serves as a request for review if it explicitly asks you to take further action, or when it indicates dissatisfaction with your decision," the manual states. And, the Dec. 7, 2000, program transmittal tells carriers not to accept an "implied request" for review from providers. "Returned remittance advices, listing or computer printouts that are not signed and/or do not express disagreement with a specified initial determination should be returned to the sender," the transmittal says.
 
Tip: To learn more on how carriers handle Medicare appeals, see the Medicare Carriers Manual Part 3, Chapter XII, Appeals Process available on the Internet at www.hcfa.gov/pubforms/14_car/3b12000.htm. Program Transmittal AB-00-122, dated Dec. 7, 2000, can also be downloaded from the Internet at www.hcfa.gov. In the search box on the main CMS Web page, type "AB-00-122" and click search. Then, click on "ab00-122.pdf." The transmittal is in pdf format and requires Adobe Acrobat software to open.

In addition to expressing disagreement with the initial determination, make sure your review-request letter includes the following information:
 

beneficiary's name.
 

Medicare health-insurance claim (HIC) number.
 

name and address of provider.
 

date of initial determination.
 

date of service for which the initial determination was issued, reported in a manner that follows Medicare claims filing instructions. Ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form.
 

which items and/or services are at issue in the appeal.

The most effective review-request letters are short and sweet, Murillo says. "They won't really read it if it's not short," she says. For example, to appeal a determination of "not medically necessary," Murillo says she would write: "Please review the attached documentation to support the medical necessity for whatever procedure on the date of service for the above referenced patient. If you have any questions, or I can provide further information, please let me know." She attaches a copy of the office-visit notes, progress notes, or whatever other documentation by the physician that supports medical necessity. "Our doctors document very well. Most of the time, the progress notes we send are self-explanatory. If I think they are confusing, or the doctor's handwriting is hard to read, I explain the reason the doctor did what was done in the letter," Murillo says.
 
With more than half of its practice consisting of Medicare patients, Murillo says the pulmonology practice requests reviews in the Medicare appeals process almost daily, and all have been settled in that step. "We've never had to go beyond the review step. It's been an ongoing educational effort with our doctors to make sure they do document well, so we can fight denials. That seems to be the key to everything for us," she says.
 
Note: Next month's issue of Medical Office Billing and Collections Alert will explain the fair hearing and further steps in the Medicare appeals process.