How To Write Appeal Letters That Work!

The ever-growing complexity of federal regulations and insurance plan rules continues to wreak havoc with the physician revenue cycle. Consider the effect on your practice of expanding global periods, bundling edits, Local Coverage Determinations (LCDs) and non-covered procedure lists.

Even the savviest medical billing staff must fine-tune the appeals process to prevent it from becoming a lengthy battle. Knowing how to write an effective appeal letter can greatly enhance your practice’s chance of getting paid for initially-denied or underpaid claims.

Use the following list of recommendations to improve your appeal letters and increase revenue:

1. Understand the content of your EOB/ERA. Look carefully to discover why the claim is being denied or underpaid. Ask yourself:
• Is the denial/underpayment due to bundling edits such as Medicare’s Correct Coding Initiative (CCI), an LCD, or a procedure’s global period?
• Did the insurance plan only pay for one procedure when two were included on the claim form?

Why this is important: The language of the appeal letter argument should address the insurance plan’s reason for denial/underpayment in a targeted fashion.

2. Know where to locate the insurance plan’s medical health and coverage policies. You’ll want to find out whether the insurance plan’s policies conflict with the accepted policies of the American Medical Association or your practice’s specialty association (for example, the American Association of Orthopaedic Surgeons). Also check whether your contract with the insurance plan includes exceptions to the policy or regulation, and whether the patient’s benefit plan covers the procedure.

Why this is important: Referencing the appropriate policy and regulation language within your appeal letter will provide the greatest chance of success. Supply a copy of all supporting documentation with your letter so that the appeal reviewer conveniently has all relevant information at his or her fingertips.

3. Be familiar with the insurance plan’s appeal process. In addition to knowing the proper forms to use, it is essential that you know the time frames allowed for submission, follow-up and response. If your first appeal letter is denied, what additional levels of appeal are possible?

Why this is important: Many appealed claims fall to the wayside when the proper appeal process and follow-up procedures are not appropriately managed. It’s important for a practice to implement a structured appeals follow-up protocol to ensure that all appealed claims are addressed in a timely manner. Treat each appealed claim like a project. Set expected milestones, including the date of appeal and expected response time. As each claim goes through the appeal process, track the level of the process it’s in, as well as the time requirement for filing.

Note: If you have exhausted all avenues with the insurance plan or feel that the insurance plan has unjustifiably denied your claim, file an external review with your state or federal insurance commission or regulatory agency.

4. Make sure the physician’s documentation is clear and complete. You’ve likely heard the old saying, “if it is not documented, it was not done.” Simply circling a CPT or ICD-9 code on a superbill does not provide supporting evidence that the procedure was performed—or medically necessary. Make sure your physicians document as much information as possible in the medical record to support any necessary appeal efforts.

5. Include as much information within the appeal letter as possible. Remember that the initial reviewer during the appeal process will make a determination based upon the presenting information. Include toward the top of your appeal letter: 1) all patient demographic information; 2) all pertinent insurance information; 3) date of service; 4) place of service; and 5) EOB/ERA denial code and reason.

Next, include: 1) evidence for the medical necessity of the procedure; 2) supporting research from the insurance plan’s medical policies, your specialty society information, the patient’s benefit coverage, etc.; 3) copies of all radiological, lab and pathology reports; and 4) any other pertinent information. Remember, the body of the letter should combat—and remain highly focused on—the insurance plan’s stated reason for denial/underpayment. Keep the letter professional.

6. Lastly, send the letter via certified mail so that you have record of its receipt by the insurance plan. As many of you know, two of the most common phrases used by insurers are, “We do not have record of that claim on file” and “We never received it”!

In summary, effective appeal writing first requires an understanding of the nature of the denial/underpayment, as well as the rules and regulations of the insurance plan and medical societies. From there, you must follow the appeal process correctly. Dispute the reason for the denial/underpayment with targeted, pertinent supporting documentation, and use certified mail to ensure that the result of your effort is received.

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