Be Appealing

By Alex Tate

Your claim has been denied.  End of story or the beginning of a new one?  One that may lead to money.

Too many practices accept denials as the end of the story, accepting the health plans “No” with a shrug, as business as usual.  But accepting no without pushing back means accepting the economic loss, and the loss of learning without a fight.  And a little fight just might work.  In fact, some studies show that while plans are denying 5%-7% of all claims, only 50% are appealed, while appeals result in additional payment 70% to 80% of the time.

Never accept a denial without challenging it.  Even if your appeal is unsuccessful you may learn from the experience as to avoid a future denial for the same reason.  In fact, many denials are based on errors of fact, correct the fact in your appeal, and you can be successful.

To be successful you will have to be able to read and understand the explanation of benefits (EOB), which everyone handling claims in an office should be able to do.  Once you know why the claim was denied, then you can appeal with the correct information.

Missing information; codes, patient demographics, modifiers, incorrect units of service, or none listed, these are the common reasons for denials.  So, appeal, sending the corrected information.  Denied for timely filing?  Your billing system (or billing company) should be able to document the “received” date from the electronic filings of your bills – proof of timely filing – appeal. Denied for lack of authorization, or referral?  Show them the documentation you have of the referral or authorization. Denied waiting for medical records, or proof of services?  Don’t wait, get the information and get it to the payer.

Critical in the process is to file your appeals promptly.  You cannot let the denials build up to get to them when you can, you never will.  Your denials need to go out within 20 days of the claims receipt.  And like a new claim, track it.  If the payer does not process and respond within 30 days, send a prompt pay complaint.

One denial you should not appeal is a denial for “other payer primary”.  This is an appeal you will not win, and what ever time you spend trying to justify that the information that your patient gave you, that you relied on is right, is most likely wrong.  And you do not have the resources to investigate, nor should you, the correctness of the payer’s position.  Sometimes the patient doesn’t know, or sometimes they want their spouses plan to cover.  There are industry rules, created by the National Association of Insurance Commissioners when it comes to coordination of benefits, and those rules, over rule the desires or designs of the patient.

If the claim is denied for “other payer primary” – bill the other payer.  Promptly.  If the denying payer does not identify the other payer, then appeal back for that information.  Appeal for payment because the “other payer” was not identified, so what evidence does the denying payer have of this other payer being primary? 

Coordination of Benefit rules may result in the patient becoming liable for deductibles or copays they were trying to avoid by misstating their coverage, however that is not your issue.  Let the patient argue with their insurance carrier.  Your role in the debate is to stand on the sidelines and get paid from someone.  If the patient challenges why you billed as you did, show them the EOB.

Appeal letters are not hard, and building a form and then a library of them on your computer will make the process easier and easier.  “Dear insurance carrier:  You denied the attached claims because…. You are incorrect because…. Attached is documentation to support the correctness of our claim.  Please make payment within 30 days of this correspondence.”

Speedily appeal denials, speedily bill the identified primary insurance.  Doing so will put more money into your practice.

Author Bio:

Alex Tate is a Healthcare IT Researcher and writer at CureMD who focus various engaging and informative topics related to the health IT industry. He loves to research and write about topics such as Affordable Care Act, EHR, revenue cycle management, privacy and security of patient health data.